Intake Form | Show & Tell

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Show & Tell Intake Form

Name

Address

Address

City

State

Zip code

Email

Home #

Cell Phone

Work #

Ethnicity *

Hispanic/Latino

No

Declined

Race

American Indian/ Native American/ Alaska American

Asian

White

Undisclosed

Black/African American

Native Hawaiian/ Pacific Islander

Two or more races:

Child's Name

Child's Date of Birth (DOB)

Person filling out this form

Parent

Grandparent

Surrogate/Guardian

Paraprofessional

Professional

Board Member

Donor

Conference Speaker

Early Childhood Provider

Educator

Calendar

Special Ed Admin

Student

Special Ed Teacher

General Ed Administrator

Administrator

Volunteer

General Ed Teacher

Legislator

Health Care Provider

Other

Disability

ADD-ADHD

Autism Spectrum Disorders

Deaf-Blindness

Developmental Delay (EC)

Emotional Disturbance

Gifted

Hearing Imp. (Inc. Deafness)

Intellectual Disability

Multiple Disabilities

No IDEA disability

Orthopedic Imp. (Physical)

Other Healh Imp.

Specific Learning Disability

Speech/Lang Imp.

Suspected/Undiagnosed

Traumatic Brain Injury

Visual Imp. (Inc. Blindness)

Other

Languages spoken other than English

Spanish

Other

Issues

Accommodations & Modification

Advocacy Strategies

Assistive Technology

Behavior

Bullying

Community resources

Show and Tell services

Developing an IEP

Disability information

How did you learn about Show & Tell?

Due Process

Early Childhood/Part C

Evaluations

Filing a complaint

Getting/defining appropriate supports/svcs

Helping school staff learn supports

IDEA

Inclusive Education Supports

Literacy

Mediation

Elementary and Secondary Education Act

Parents rights & responsibilities

Placement/LRE

Respite

Section 504

Standards/PARCC

Transition/Adulthood

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Thank you for filling out our intake form. A member of our team will be in contact shortly!

CONTACT

3131 S Vaughn Way #214

Aurora, CO 80014

303.632.6840

Info@WeShowAndTell.org

The contents of this website were developed under a grant from the U.S. Department of Education, #H328C210014 However, those contents do not necessarily represent the policy of the U.S. Department of Education, and you should not assume endorsement by the Federal Government. Project Officer, Yolanda Lusane.

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