Network Program Enrollment Form

Center for Neurodiversity Education, Support and Training (NEST)

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Please complete the following:

Group Member Information

Name

Gender identity

Male

Female

Nonbinary

Other

Race & Ethnicity

White/Caucasian

African American

Hispanic

Asian

Native American

Pacific Islander

Other

Age

Address

Phone number

Email address

Diagnoses

Date of diagnoses

What do you hope to get out of The Network group?

Parent / Guardian Information

Name(s)

Address(es) (if different from above)

Telephone number(s)

Email address(es)

How did you hear about The Network Program?

Why would you like your son/daughter to participate in The Network Program?

Do you have any questions or concerns about The Network Program?

*Required fields

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