PADDA Request For Assistance

Please supply the following information about your particular situation so that we can assist you.   If you have an inquiry about Educational Issues and Children with Special Needs , we will do whatever we can to assist you and to provide resource referrals  (where available) for your child. 


 The information that you provide below will be kept confidential and are being submitted to PADDA over a secure server connection.

 

STEP ONE

      


How did you learn about PADDA?
   

STEP TWO

      


Information About Yourself

 Information indicated by Red is Required so that we might be able to contact you or to provide you with information about your request.

Parent Name  

   Parent Street Address  

   City  

State  

Zip Code  

Email Address  

Home Phone Number  

Work  Number  

Your Ethnicity  

 used only for grant reporting purposes

Is either you or your spouse currently in the military?  

   used only for grant reporting purposes

Are you the child's parent?  

If not, what is your relation?  
.

STEP THREE

 . . .


Information About Your Child

 If you have more than one child with special needs issues, please complete this form again for each additional child.   
This form is designed for only one child.
Child's Name   
Child's School   
City School is Located    
State School is Located   
Child's Age   
Child's Gender  
Is Child Currently Receiving Special Education Services?  
Does the Child Currently Have an IEP? 
Has the Child Been Suspended This School Year? 
If so, for how many total days?
.

STEP FOUR

 . .. .


The nature of my inquiry is that I have a.....

Please provide a brief description of the problem
.

STEP FIVE

 . . .


Please select which disability your child has...


Should your child's disability not be on the list above, please enter it now...
.

STEP SIX

 . . .


Did you provide either a phone number or email address where we can reach you? 

Click here to go back to the top to review your entries


Use "clear" only if you wish to erase ALL entries


Return to PADDA's Main Page

Thank you for providing the information listed above.  
All information provided is confidential.  

Your information will be forwarded to PADDA and if you requested a response, one will be forthcoming as soon as possible.  

PADDA, People With Attentional And Developmental Disabilities Association
Copyright © 1999-2002  All rights reserved.
Revised: 09/23/02