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
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




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