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Student's Name *

Parent's or Guardian's Name *

County of Residence *

School District *

School of Attendance *

Does your child have an Intellectual/Developmental Disability? *YesNoRequesting Evaluation

Please describe your child's diagnosis

Does your child have an IEP? *YesNoRequesting Evaluation

What was the advocacy goal for your student? (Reason you contacted The Arc of Southwest CO) *

Has the advocacy goal been met? *YesNo

How often would you like your Education Advocate to follow up with you?

Best way to contact you *PhoneEmailTextU.S. Mail

Email Address *

Phone *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Would you like information on our support groups?YesNo

Would you be interested in attending trainings (check all that apply)?Supported Decision Making and Guardianship info and processTransition PlanningSpecial Needs Trusts and set up

Suggested IEP trainings

Comments and questions

How did you hear about us? *

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