Find My Family

INSTRUCTIONS:

Please answer all the questions as best as you can, and click on the "Submit Your Responses" button at the bottom of this page. We won't let you leave some of the questions blank. These are marked with a red asterisk.*

All this information is about the person with a disability. If you are the advocate for this person, enter your information at the bottom.

Please provide the following:

I AM LOOKING FOR MY FAMILY

This section about the person with a disability who is seeking a connection with his/her family. It may be filled out by a person with a disability or the advocate for such a person.

1. Enter your date of birth (mm/dd/yyyy): *

   01 02 03 04 05 06 07 08 09 10 11 12 / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /

2. Your gender is: *

   Male
   Female

3. Your ethnic origin is: *

   Caucasian
   African American
   Latino
   Indian/Asian
   Pacific Islander
   Native American
   Other (please specify)

4. Enter the city where you were born: *

5. Enter the main zip code of the city or town where you were born (find zip codes): *

6. In what year did you last see or talk with your family (yyyy)?

7. Who was the last family member you talked to?

8. Tell us the names of your family members:

9. Fill in the main zip code of the last place where you lived with your family (find zip codes):

10. Fill in the zip code where you live now (find zip codes): *

11. Fill in the name of your current residential provider, if you have one:

12. Use this space to provide any more information about your family that might help in finding them:

13. If there are any family members you DO NOT want to talk to, please enter the names here:

ADVOCATES

If you are the advocate giving information on a person with a disability, please fill in all the blanks below:

THANK YOU!

Click on the "Submit Your Responses" button below to send your information. If you have left anything out, you can go back and fill it in.