Dance for Joy Youth with ADHD
An 8-week Program: March 5-April 30, Thursdays, 3:30-5:00

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Student Last Name *
Student First Name *
Student Email *
Student Pronouns *
Student's Current School *
Student's Current Grade *
Does the student have a confirmed diagnosis of ADHD? Do they have any other related diagnoses?
What are the student's biggest challenges in terms of their ADHD and school? *
Caregiver/Parent/Guardian Last Name *
Caregiver/Parent/Guardian First Name *
Caregiver/Parent/Guardian Email *
Caregiver/Parent/Guardian Phone Number *
Emergency Contact - please provide name, relationship, and phone number  *
Anything else we should know? Allergies? Accessibility needs? *
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