Youth ADHD Program Application Form

Applicant's Full Name

First NameLast Name

Date of Birth

Date

Gender

Parent/Guardian Full Name

First NameLast Name

Parent/Guardian Email Address

example@example.com

Parent/Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Has the applicant been diagnosed with ADHD by a healthcare professional?

Please describe current symptoms, challenges, or behaviors related to ADHD.

Is the applicant currently receiving any treatment or support for ADHD?

Relevant medical history or co-occurring conditions (e.g., anxiety, learning disabilities)

Current school and grade level

Please share any accommodations or support the applicant receives at school

Reason for applying to the Youth ADHD Program

Has the applicant previously participated in any ADHD programs or support groups?

Emergency Contact Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Signature of Parent/Guardian