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Learning Disabilities Associations within Peel Region

Please complete the following information as completely as possible. Once submitted, an LDA staff member will contact you to discuss your application and payment.

Program I would like to register for:
I am registering for myself
I am registering my child
Participant First Name
Participant Last Name
Male
Female
Adult (18+)
Teen (13-17)
Child (12 or younger)
Date of Birth (if under 18)
Grade (if applicable)
Parent / Guardian Name
Address
City
Postal Code
Home Phone
Work Phone
Cell Phone
Email
Has participant been formally diagnosed as learning disabled?
Has participant been formally diagnosed as ADD/ADHD?
Has participant been identified with any other exceptionality? If yes, please specify.
Please identify any behavioural concerns
Please identify and medical concerns
Please identify any allergies
Please list any other instructions or information