RCADD Services Application

RCADD Services Application Heading link

RCADD Services Application
Need support for your child or student with autism or developmental delays? Fill out the service application below!
Applicant Info
Name * Required
First Middle Last
Address * Required
Street Address City ZIP Code
Home/ Cell Phone # * Required
Email * Required
Employment Info (for educators & professionals)
Employer
Work Phone #
Work Address
Street Address City ZIP Code
Patron Type * Required
For "Other Professional", please specify your title
Child's Age * Required
Child's Diagnosis * Required
Do you have a child enrolled in Head Start? * Required
Are you currently employed by Head Start? * Required
If you answered yes to either of the top two questions, what site are you currently affiliated with?
How did you hear about us? * Required
If "Other", please specify
Any other information you'd like to share
Should a lending library item be lost or damaged, RCADD patrons will act within their means to replace the exact item or one with a similar subject matter. By providing RCADD with your email, you will be enrolled in our monthly online newsletter. By signing and dating below, you agree to the above requests.
Signature * Required
Date * Required
MM slash DD slash YYYY
Consent * Required
I agree to the privacy policy.