CHADD Mentoring Program Application

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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:

Parent of a young child	Adult
Parent of a young adult	Psychologist
Other Mental Health Professional	Educator
Physician	Coach
Other (please specify below)

Other interests:

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