SNAP Online: Special Needs Advocate for Parents

First Name:
Last Name:
Address:
City:
State:
Zip:
Home Number:
Work Number:
Best Time to Reach You:
How did you hear about us?

Have you read our privacy policy and disclaimer regarding your personal information?
	Yes, I have read the policy and I give you permission to disclose my information if and when SNAP needs to.
	No, do not disclose any of my personal information.

Email Address:
Would you like to receive the SNAP newsletter?
Yes, via mail Yes, via e-mail No, Thanks

What topics are you most interested in?*
	Protecting government eligibility
	Educational advocacy
	Estate planning
	Medical insurance problem solving
	Other

Please choose.
	I would only like to receive the newsletter at this time.

Thank you for requesting our newsletter, The SNAP Report. You will be added to our mailing list.
Please be sure to click on the submit button below to complete your request.

I would (also) like assistance with Estate Planning.

Check all that apply:
	I am a special needs parent.
	I am a special needs professional.
	I am a family member.
	Other (please explain):
What is the age of the person with special needs?

What are the person's special needs?

Does the child live at home? Yes No
How many other children do you have?

If so, what are their ages?

Does the child currently receive government benefits?

If so, which ones?

I would (also) like assistance with Medical Insurance Problem Solving.

What is the age of the person with special needs?

What are the person's special needs?

Does the child live at home? Yes No
Are you seeking?
	reimbursement authorization
	For what service?
Have you and/or your doctor already requested the service, equipment, therapy, etc. from the insurance company?
	Yes No
	If so, when? (Please provide date.)
Have you received a response from the insurance company?
	Yes No
	If yes, what date did they respond to your appeal in writing?

I would (also) like to request a speaker from SNAP for my organization.

Are you interested in becoming part of SNAP's resource directory? Yes No
	Name of organization*

	Contact Person

	Size of audience*

	Date, time, and location of presentation*

Audience consists of?*
	Families who have a special needs individual
	Adults with disabilities
	Special needs professionals
	Mixed
Speaker paid* Yes No
Expenses paid/reimbursed* Yes No
Will the presentation be*
	Main platform
	Concurrent discussion
	Panel Discussion
What type of group is this?*
	National conference
	Support group meeting
	Other (please explain)

I am a special needs professional and would like to be added to SNAP’s resource list.

What is your expertise (describe in detail)?*

How long have you been working in this field?

Please describe your prior public speaking experiences*

Have you ever been published?* Yes No
	If yes, then where and when?
What percentage of your business deals with families who have children with disabilities?*

What are your fees*
	None Hourly Income based
	Fixed fee Other:

What special needs organizations do you belong to?

Do you subscribe to any special needs publications?
	Yes No
If so, which ones (e.g., "Exceptional Parent Magazine")?

What other information would you like to see on our Web site?

Is there any additional information that you would like share with us?

Thank you for taking the time to complete this form. Your information will be reviewed and you will hear from us shortly.

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