Serving families of the Mid-State Region of New York State

Contact Us

Promoting meaningful parent involvement in the inclusive education of children with disabilities.

TEL 315-443-4336 | Toll-free 877-824-9555 | FAX 315-443-4338 | supac@syr.edu

Name *
Parent/Guardian Professional (Title &/or Agency)
Phone *
Alternative Phone (ie. Cell Phone)
Email
Address
City *
State *
Zip *
County *
School District *
Building
Ethnicity	African American Asian Caucasian Hispanic Native American Unknown or Other
Child/Student’s Name *
Age *
DOB *
Child's Ethnicity	African American Asian Caucasian Hispanic Native American Unknown or Other
Disability/Classification on IEP *
Other Disability or suspected disability
How did you hear about our program? Check all that apply.	Previous Contact Other Parent Professional Media Phone Book SU Website Other Website Search Engine Agency Literature Service Provider Presentation Other
Reason for Contact? Check all that apply.	Abuse/ Neglect/ Exploitation Education/ Advocacy /Medicare/ Medicaid ADA (American’s with Disability Act) Disability/Information on Medical/Therapeutic Agency Information Financial (SSI/SSD) Support Assistive Technology Guardianship Transportation Vocational Legal/ Advocacy 504 plan CSE meeting Trainings Transition Other
Preferred method of contact	Phone (best time to call) Email Please mail me information