Parent Mentor Program | Trusted Parents

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제공된 정보는 NC 가족 지원 네트워크 및 Trusted Parents에서 부모 연결을 위한 목적으로만 사용됩니다.

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잠시 시간을 내어 양식을 완전히 작성해 주시기 바랍니다.

Which service are you interested in?

Request a Parent Mentor

Become a Parent Mentor

Parent's Full Name

What city do you reside in?

What county do you live in

Preferred Phone Number

Email Address

Preferred method of contact? (check all that apply) 필수

Phone Call

Text

Best time to be contacted?

Primary language spoken

Occupation

If not parent, please provide name and telephone number of person fillout the form

Full name of child(ren)/individual with special healthcare needs

Age of child

List diagnosis or condition and age at the time child was diagnosis:

NICU?

Yes

If yes, for how long?

Gestational age at birth?

Tell us more about your child(ren) (i.e. educational needs, mobility, medical equipment, adaptive equipment, surgery, specialized living setting, behavior challenges, services, and therapies received, adopted, foster, etc.)

Please include any special concerns you may have for your child

If you have multiple children with special healthcare needs, please list name, age, gender, and diagnosis below:

I give permission for Family Support Network and Trusted Parents to release my name and number to another FSN program affiliated/parent for the sole purpose of making a successful match.

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학부모 멘토 정보 양식

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