Group Home Visitation RequestThis form is a request to explore possible partnership and dates of visitation to a group home in the Chicago-land area.Group Home (GH) Representative Name* First Last GH Representative Email* GH Representative Phone*Zip Code of Group Home*# of Residents in Group HomePlease enter a number from 1 to 30.Gender of GH Residents*Select OneMaleFemaleMixedDisability TypesWe don’t like labels- but they can be helpful in providing a minimal level of understanding. (Please check all that apply) Intellectual Developmental Physical Deaf/ Hard of Hearings Blind Mental HealthHow did you hear about 139 Friends?* Invited by Friend Website/Google Twitter/Facebook We're a 139 Family OtherIf "other," please specifyΔ
