Facing Autism Challenges Together
Mail
to: F.A.C.T. c/o
Fax to: 952-935-4354
E-Mail to: HopkinsFACT@comcast.net
F.A.C.T. – Facing Autism Challenges Together – welcomes you as a participant to our group as we bring together families living with Autistic Spectrum Disorders for support, information, and networking opportunities.
We use your personal
information below to communicate with you, to provide you with educational and
support information about Autistic Spectrum Disorders (ASDs) we think will be
of interest and value to you, and to place you in contact with other families
living with ASDs. Please share as much
or as little information as you choose.
The more we know about you, the more we customize the information we
send you. Your personal information
is for the sole use of F.A.C.T. and will not be shared with any other person or
organization without your consent.
As a non-funded, volunteer organization, E-Mail is the main way we communicate with you between meetings. To maximize the benefits of F.A.C.T. registration, it is very important to keep a current E-Mail address on file with us. We will rarely telephone you unless you ask us to. By giving us your E-Mail address, you consent to receiving regular F.A.C.T. informational E-Mails until you direct otherwise.
Please initial the
things you agree to:
________ I consent to release of my personal information to other F.A.C.T. registrants to facilitate communication and networking between my family and other F.A.C.T. families.
Today’s Date:
______________ [ ] First Time Registration [
] Update Registration
E-Mail Address:____________________________________________ Home Phone:
___________________
Adult 1 Name:
____________________________________ Phone [
] Work [ ] Cell: ____________________
Adult 2 Name:
____________________________________ Phone [
] Work [ ] Cell: ____________________
Address:
County:
___________________________ Does ASD
child receive any county services or aid? [
] Yes [ ] No
# of
Children:
Child 1 Name:
_________________________ D.O.B. ____________
Sex: M F
Sch. Grade: ___________
School:
________________________ Special
needs? [
] Yes [ ] No
Has School IEP? [ ] Yes [ ] No
Diagnosis [
] Medical [ ] Sch. Dist.:
_____________________________________________ When? ________
Child 2 Name:
_________________________ D.O.B. ____________
Sex: M F
Sch. Grade: ___________
School:
________________________ Special
needs? [
] Yes [ ] No
Has School IEP? [ ] Yes [ ] No
Diagnosis [
] Medical [ ] Sch. Dist.:
_____________________________________________ When? ________
Child 3 Name: _________________________
D.O.B. ____________ Sex: M F
Sch. Grade: ___________
School:
________________________ Special
needs? [
] Yes [ ] No
Has School IEP? [ ] Yes [ ] No
Diagnosis [
] Medical [ ] Sch. Dist.:
_____________________________________________ When? ________
(If you wish to report
additional children, print a second copy of this page.)
How did you learn about FACT?
______________________________________________________________
Please see and complete the Interests / Concerns Survey on
back of this form.
Revised 07/07/2008
Interests
/ Needs Survey
Please mark your present level of interest in or need for the following:
|
Topic |
Strong Interest / Need |
Somewhat Interested /
Needed |
Not Currently Interested
/ Needed |
|
Advocating for my child’s
educational needs |
|
|
|
|
Behavior management and
discipline strategies |
|
|
|
|
Books and materials to help my
child understand ASDs |
|
|
|
|
Community resources /
organizations |
|
|
|
|
Government financial assistance |
|
|
|
|
Hearing professionals speak on
topics that relate to my child: |
|
|
|
|
Helpful books or websites on
topics that relate to my child: |
|
|
|
|
Networking with other ASD
families |
|
|
|
|
Post-secondary education options
with ASD |
|
|
|
|
Respite care (time off from
parenting) |
|
|
|
|
School year friendship /
socialization opportunities |
|
|
|
|
School year recreational
activities |
|
|
|
|
Sibling / family /
extended-family issues re ASD |
|
|
|
|
Summer-time friendship /
socialization opportunities |
|
|
|
|
Summer-time recreational
activities |
|
|
|
|
Support with parenting issues |
|
|
|
|
Talking with other parents about
daily stresses or for advice |
|
|
|
|
Toilet training or other
age-level hygiene issues |
|
|
|
|
Transition (to adulthood)
planning and services |
|
|
|
|
Treatment and therapy
alternatives for ASD |
|
|
|
|
Teenage issues: Dating, Driving, Sexuality, Drugs, etc. |
|
|
|
|
Other: |
|
|
|
|
Other: |
|
|
|
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