Franklin SEPAC Mailing List and Survey

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The purpose of this form is to find out more about what you are looking to get out of SEPAC. Your contact email address is the ONLY MANDATORY FIELD and will be used to share information with you about news and events. All other information is optional and will not be shared - it will be used for planning of events and initiatives.

Thanks!

(If you have questions about this form, please email franklinsepac@gmail.com.)

Email Address *

All questions below are OPTIONAL, and your responses will only be shared with SEPAC Board Members for planning purposes.

First Name

Last Name

Phone Number (Please enter in the format 555-555-5555)

My children are currently attending:

Hellen Keller Elementary

Jefferson Elementary

Kennedy Elementary

Parmenter Elementary

Annie Sullivan Middle School

Horace Mann Middle School

Oak Street Elementary

Remington Middle School

Franklin High School

Other:

Topics That Interest Me/My Family

In the following section, please check any/all topics that you would like to hear more about. This will help the SEPAC leaders gear activities/communications towards topics impacting as many families as possible. Please understand that we can't guarantee to cover everything, but we will do our best!

For more information on topics 1 through 13, please go to https://www.understood.org/articles/en/conditions-covered-under-idea. These are categories of eligibility from IDEA (https://sites.ed.gov/idea/about-idea/) but you don't need to have a student with an IEP in these areas to express interest.

Please use "Other" to indicate any additional topics, and "Topic Comments" if you would like to indicate a more specific area of interest, or any other question/concern.

Topics that I would like to learn more about:

1.Specific learning disability/SLD (ex. Dyslexia, Dyscalculia, Dysgraphia/Written Expression Disorder)

2. Other Health Impairment/OHI (ADD and AH/HD, Diabetes, Epilepsy, Heart conditions, Hemophilia, Lead poisoning, Leukemia, Nephritis, Rheumatic fever, Sickle cell anemia, Tourette syndrome, and others)

3. Autism Spectrum Disorder/ASD

4. Emotional Disturbance

5. Speech or Language Impairment

6. Visual Impairment, Including Blindness

7. Deafness

8. Hearing Impairment (other than Deafness)

9. Deaf-Blindness

10. Orthopedic Impairment

11. Intellectual Disability

12. Traumatic Brain Injury

13. Multiple Disabilities

14. Executive Functioning Skills

15. Challenging Behavior

16. Anxiety/Depression

17. Preventing and Responding to Bullying/Discrimination/Harassment

18. Transitioning / Adult Dependents / Custodial Care / Guardianship

19. Advocating (Local/State/Federal Legislation)

20. Advocacy Resources (for parents/caregivers in regard to caring for their children)

21. Local Recreation Accessible to Children with Disabilities (camps/parks/clubs/local destinations/etc.)

22. Parent/Caregiver Resources and Support (in regard to caregiver self-care) / Respite Care / etc.

Other:

Topic Comments:

How I would like to interact with other SEPAC members:

Virtual Parent/Caregiver Meetups (Informal)

Virtual Parent/Caregiver Workshops

In-person Parent/Caregiver Meetups (informal)

In-person Parent/Caregiver Workshops

Parents' Night Out

Family Friendly Events

I am available for parent/caregiver-focused events:

Weekday mornings

Weekday afternoons

Weekday evenings

Weekend mornings

Weekend afternoons

Weekend evenings

Are you in a profession or do you have expertise in a topic that other SEPAC members might like to hear about? If so, please let us know more about that topic/profession and how you would like to contribute.

Would you be interested in becoming a future SEPAC leader or board member? If yes, is there a particular role you are interested in?

Additional comments/questions/suggestions:

Submit

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