Registration is free.
Please note this group is for Adults with a Learning Disability
21 years of age
and older
Please only register on-line and you must have an e-mail address
First Name
!
Mandatory
Last Name
!
Mandatory
Applicant's Age
!
Mandatory
Applicant's Birthday
(MM/DD/YYYY)
What is your specific disability?
!
Mandatory
Address
!
Mandatory
Address
City
!
Mandatory
State/Province
Not in USA or Canada
AK-Alaska
AL-Alabama
AR-Arkansas
AZ-Arizona
CA-California
CO-Colorado
CT-Conneticut
DC-District of Columbia
DE-Delaware
FL-Florida
GA-Georgia
HI-Hawaii
ID-Idaho
IL-Illinois
IN-Indiana
IA-Iowa
KS-Kansas
KY-Kentucky
LA-Louisiana
MA-Massachusetts
MD-Maryland
ME-Maine
MI-Michigan
MN-Minesota
MO-Missiouri
MS-Mississippi
MT-Montana
NC-North Carolina
ND-North Dakota
NE-Nebraska
NV-Nevada
NH-New Hampshire
NJ-New Jersey
NM-New Mexico
NY-New York
OH-Ohio
OK-Oklahoma
OR-Oregon
PA-Pennsylvania
RI-Rhode Island
SC-South Carolina
SD-South Dakota
TN-Tennessee
TX-Texas
UT-Utah
VT-Vermont
VA-Virginia
VI-Virgin Islands
WA-Washington
WI-Wisconsin
WV-West Virgina
WY-Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
NorthWest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territories
Zip/Postal Code
!
Mandatory
Email Address
!
Mandatory
Home/Work Phone
!
Mandatory
-
Cell/Mobile Phone
-
Company (If you are employed)
Please specify a Username and Password for your FREE access and remember them as you will use them the next time you login to this web site.
Your Username
!
Mandatory
Your Password
!
Mandatory
Are you a returning member/guest?
No
Yes
Returning to the group? Who do you know
Comments:
Registration Form Completion:
Who completed or assisted with this submission:
!
Mandatory
Self
Parent
Guardian/Other
Parents/Guardian's e-mail Address
Your IP is: 3.235.75.174
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