If you live in Nevada and would like to be matched with a Support Parent, you can fill out this Request Form:
* = Required
Parent's (or Caregiver's) Name
Relationship to person with special need:
*Home Phone: ( )
Best Time to Reach Me at Home:
Is it OK for us to call you at work? Yes No
Work Phone: ( )
Best Time to Reach Me at Work:
Fax: ( )
Person With Special Health Care Need or Disability
We will protect all information that is provided to Parent to Parent including names, addresses, phone numbers, birthdates and medical information.
DOB: / / (mm/dd/yy)
When was disability diagnosed?
At the age of
List all disabilities or conditions
Other children names and ages
Please include any additional information about your child that might assist in making a good match, i.e., twins, disability the result of an accident, play/social skills, hobbies/interests, etc. If you would like to speak to another parent about a specific topic related to your child, please indicate.
Please include any special issues or concerns you may have regarding your child.
I would like to be contacted by Parent to Parent of Nevada to explain my request further.
Parent to Parent has my permission to release my name, phone number and/or Email address to a trained support parent in order to complete this request for a parent match.
Reno Office: 3100 Mill Street, Suite 117 Reno, NV 89502;
P: (775) 823-9500; F: (775) 323-2205; E: firstname.lastname@example.org
Las Vegas Office: 6130 Elton Avenue, Suite 100 Las Vegas, NV 89107
P: (702) 740-4200; F: (702) 216-0321;
Statewide Toll Free: (866) 326-8437;
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