Parents as Partners in Professional Development (P3D) Sign-up Form

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Yes! I am a family member of a young child who is (or was) receiving Early Intervention services in Pennsylvania.

I am interested in being included in the P3D directory database and receiving information about upcoming opportunities for family engagement, leadership development, informational sessions, and networking events.

Email *

First Name: *

Last Name: *

Address:

County:

Telephone number:

What is your race?

Black or African American

White or European American

American Indian or Alaska Native

Asian

Native Hawaiian or other Pacific Islander

Two or more races

Prefer not to answer

Other:

What is your ethnicity?

Hispanic or Latino

Not Hispanic or Latino

Prefer not to answer

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CHILD 1: Birth date of your child who is (was) receiving Early Intervention Services: *

YYYY

CHILD 2: Birth date of your child who is (was) receiving Early Intervention Services:

(optional)

YYYY

CHILD 3: Birth date of your child who is (was) receiving Early Intervention Services:

(optional)

YYYY

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