What is PPMD and Good Samaritan Law Workshop - Howard County Library Registration Form

Please complete this form to pre-register for the 'What is PPMD' and 'Good Samaritan Law' workshop at the Howard County Library - East Columbia Branch (6600 Cradlerock Way, Columbia, MD 21045) on December 16th 5:30 - 6:30pm.

Registration is not required to attend.

This is not an official Howard County Library System event. For more information, contact Kim at 410-768-9100.

First Name

Last Name

Phone

Please describe yourself

Parent/GuardianOther relativeStudent/YouthProfessional

Organization/Company Name

What is your county of residence?

What is your race? (This question helps PPMD to ensure we are reaching everyone in our community and to receive grants to fund our programming.)

American Indian or Alaska NativeAsian or Asian AmericanBlack or African AmericanNative Hawaiian or other Pacific IslanderWhite or CaucasianTwo or more racesOtherPrefer not to answer

What is your ethnicity? (This question helps PPMD to ensure we are reaching everyone in our community and to receive grants to fund our programming.)

Hispanic or LatinoNon-Hispanic or LatinoPrefer not to answer

What is the age of your child(ren)?

What is the gender your child(ren)?

What is the race of your child(ren)? (This question helps PPMD to ensure we are reaching everyone in our community and to receive grants to fund our programming.)

American Indian or Alaska NativeAsian or Asian AmericanBlack or African AmericanNative Hawaiian or other Pacific IslanderWhite or CaucasianTwo or more racesOtherPrefer not to answer

What is the ethnicity of your child(ren)? (This question helps PPMD to ensure we are reaching everyone in our community and to receive grants to fund our programming.)

Hispanic or LatinoNon-Hispanic or LatinoPrefer not to answer

Please check any disabilities your child(ren) has:

AutismADD/ADHDDeaf/BlindDevelopmental DelayIntellectual DisabilityDeaf/Hearing ImpairmentEmotional DisabilityLearning DisabilityMultiple DisabilitiesOther Health ImpairmentOrthopedic ImpairmentSpeech and LanguageTraumatic Brain InjuryVision Impairment/BlindSuspected DisabilityNoneOther

Please select if your child has an IEP or 504 plan

Individualized Education Program (IEP)504 planNone

Contact Information