Become a Supporting Parent

Name (required)

Date (required)

Referred by

Address

City

Zip Code

School District/County

Phone

Occupation

Email

Highest level of education
GEDHSCollegeGrad School & above

Marital Status:
MarriedDivorcedSeparatedSingleWidowed

Nationality

Primary Language

Spouse's Name

Name of each child with their Date of Birth and Gender

Child(ren) with Special Needs

Name(s)

Gestational age at birth

Hospital born in

Primary Diagnosis

Other Diagnosis, symptoms or areas of concern

Agencies providing for your child

Why I would like to become a mentor

Special areas of knowledge (ex: NICU, gtube feeding, seizure medication, etc)

Resources I would like to receive

I am interested in the following:
Continued Education about my child’s special needs.'How to tell my story' trainingEducation AdvocacyState or Federal Legislation AdvocacyLearning about other opportunities to volunteer for the Oklahoma Family NetworkStarting a support groupParticipating as a parent advocate on state or local councils, committees and boards

All information submitted into the OFN database will be kept confidential.

Or you can apply using our Supporting Parent Application as a pdf and email to heather-pike@ouhsc.edu or mail to:

Heather Pike
Center for Learning and Leadership/UCE
P.O. Box 26901 ROB 342
Oklahoma City, OK 73190

405-271-4500 Ext 41014