Workshop Questionnaire Form

Workshop: Creating a Well-Rounded Leader for the Future Questionnaire
Thank you for your interest in our Workshop, Creating Well-Rounded Leaders for the Future!

Please fill out the questionnaire below. These answers will help us design the perfect program for your family! After we receive your questionnaire, we will send you a registration form.

Space is limited so don't delay!
What is the participant's name:

First NameLast Name
Email:
example@example.com
Age:
Phone Number:

Area CodePhone Number
Diagnosis:
What do you want to achieve with the workshop?
What is your attention span? (time: minutes)*
How long can you remain seated and working on a task? (time: minutes)*
What is your ability to understand information and/or instructions and ability to perform.

Other
What is your emotional maturity:

Other
Will you require individualized assistance?
Any individual situations we should know about:
Diet Restrictions (Example - Vegetarian, Gluten Free etc.):
Food Allergies, if any
Comments:
I hereby give my consent to Wellness Institute of Neurodevelopment to photograph, film, and/or videotape and then use, reproduce, and publish the following images of me and/or my child/children for marketing purposes.
Name of caregiver (if participant is younger than 18 y/o)

First NameLast Name
Date of Signature

MonthDayYear
Participant’s signature (if older than 18 y/o) or caregiver’s signature
Please verify that you are human
Should be Empty:

Workshop: Creating a Well-Rounded Leader for the Future Questionnaire