Role of a SEPAC Registration

Role of a SEPAC Registration Form 11.21.2023

The Federation for Children with Special Needs is funded by grants which require us to collect data. Our registration is confidential and used to ensure we are supporting all communities. We do not share personal information, nor do we sell to third parties. Please contact us with any accommodation requests at lleslie@fcsn.org.

First Name(Required)

Last Name(Required)

Email(Required)

Address

State

City

Out of State City

Zip/Postal Code(Required)

Organization

Gender Identify

Preferred Phone Number

Cell Phone

Home Phone

Work Phone

Age of child with special needs?(Required)

Primary Language(Required)

Other Language

Are you attending this event as a (check all that apply):(Required)

Parent/Caregiver

Foster Parent

Grandparent

Student (14-22)

Professional Educator

Professional Other

Special Education Decision Maker (SESP)

Other

What is your race?(Required)

What is your ethnicity?(Required)

What is your child's race?(Required)

What is your child's ethnicity?(Required)

What is your child's primary disability?(Required)

What is your child's secondary disability?

What is your total household income?

What is the highest level of education that you have completed?

How many family members are in your household?

Specify race

Specify child's race

What question do you have for the presenter?

Role of a SEPAC Registration Form 11.21.2023

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