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CHADD, Children and Adults with Attention Deficit/Hyperactivity Disorder

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Personal Information
Fields marked with '*' are required.

* Last name:
* First name:
Title:
Middle:
* Pref'd Address:
2nd address line:
* City, St/Prov:
Zip:
Home Phone:
Work Phone:
* E-mail:
Fax Phone:

Demographic Information
Fields marked with '*' are required.

* I am a:	Parent/Guardian Adult with AD/HD Educator Professional (Counselor, Psychologist, Psychiatrist) Student Spouse of an AD/HD Adult Other
Gender:	Male Female
Ethnicity:	Hispanic/Latino Not Hispanic/Latino
Race:	American Indian or Alaska Native Asian African American Native Hawaiian or Other Pacific Islander Caucasian
Birth date:
Occupational Status:	Student Employed Homemaker Not Employed Retired

* Support Group Options (only one)

	1. Yes, I am interested in establishing a new support group in my area. I understand that the main purpose of is to share information and mutual support related to experiences with AD/HD.
	2. Match me with a partner; I would like to be matched up with a partner/co-facilitator in my area so we can share the responsibility of starting and facilitating. I understand that that CHADD may be unable to locate another individual near me and if I still have an interest in starting one on my own, I should contact the CHADD national office chapter services department.
	3. New support group for Spanish speaking participants (CHADD has materials in Spanish available)

Anything else?

* Type the letters shown in the picture below

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