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Participant Application
Application for Neurodiverse adults to Join the Special Pedals Team
Email *

Full Name:

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Street Address

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Telephone (Mobile):
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Guardian Telephone: (If not Applicable type N/A)
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Support Person Info (Name & Phone number)
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Email: *

Level of support required (choose one)

Most Recent Work / Volunteer Experience
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Area of Preference (Check All that Apply)
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Required
Availability
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Please list the names and contact information of three  references (One may be a relative)



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“I understand that Special Pedals Inc. pairs participants with mentors to instruct individuals to help them realize their potential.  I authorize Special Pedals Inc. to contact my references to provide and verify any information that they have regarding me and release them from any liability arising from furnishing any information.”

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