Application for Strength in Neurodiversity Social Group
Child's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Contact Information
Parent(s) Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please select if your child identifies with any of the following (multiple answers can be selected)
Autistic Spectrum Disorder (ASD)
ADHD
Intellectually Disability
Specific Learning Disorder
Does you child need additional support? (eg. assistance using a bathroom, support communicating)?
Yes
No
If there is any additional information that you think would be beneficial, please list below.
How did you hear about the program?
Submit
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