Project KITE

Parent and Child information

*Address: A value is required.

*City: A value is required. *State: A value is required. *Zip: A value is required.Invalid format.

*Phone (h) A value is required. (work/cell) A value is required.

*E-Mail: A value is required.Invalid format.

(optional)Cultural background: - African-American Hispanic Hmong Native-American Asian-American Caucasian Other
If Other please specify A value is required.

*Child's name: A value is required.

*Child's date of birth A value is required.Invalid format.

(optional)Child's cultural background - African-American Hispanic Hmong Native-American Asian-American Caucasian Other
If Other please specify A value is required.

*Child’s School: A value is required.

*Child's teacher: A value is required.

*Child's grade in school: A value is required.

Teacher/Service Provider and Child information

*Student's name: A value is required.

*Job Title: A value is required.

*School/Facility name: A value is required.

*School address: A value is required.

*City: A value is required. *State: A value is required. *Zip: A value is required.Invalid format.

*Phone: A value is required. (h) (cell/work) A value is required.

Email: A value is required.Invalid format.

(optional)Cultural background: - African-American Hispanic Hmong Native-American Asian-American Caucasian Other Please select an item.
If Other please specify A value is required.

Assistive Technology and Computer Skills Section

*Describe child's strengths: A value is required.

*Estimate your computer skill level (1- no experience to 10- expert A value is required.Invalid format.

*Do you own a computer? Yes No
Please make a selection.

*Primary Computer type: PC MAC
Please make a selection.

*Does the child use a computer at school? Yes No
Please make a selection.

*Do you currently use assistive technology (AT) with the child? Yes No
Please make a selection.

What AT does the child currently use? A value is required.

What AT would you like to learn more about?

Why do you wish to participate in Project KITE?

By Submitting this application you acknowledge that if accepted into Project KITE you will attend the training sessions and work with the team for the benefit of the child.