Please print and Fax to 301-306-7091 or Scan and Email to CHADDConference@chadd.org
Name:
Title (if applicable):
Email:
Address:
Telephone:
Fax:
I would like to be a:
Mentor
Mentee
I am a:
CHADD Board of Directors Member
CHADD Coordinator
(Mentors only) I have been a CHADD member at least one year and have attended a CHADD Annual International conference:
Yes
No
Type of Member:
Family
Professional
Educator
Vendor/Exhibitor/Sponosr
Student
Other (please specify below)
:
Parent of a young child
Adult
Parent of a young adult
Psychologist
Other Mental Health Professional
Physician
Coach
Other interests:
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