Family Participant Application

Family Member Participant Information-WTD Course (Non-parent)

Please enter the information of the relative / guardian where 'other' was selected on previous application form.

Name:(Required)

First Last

Phone:(Required)

Email:(Required)

Occupation:(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Full Name of Child:(Required)

Relationship to Child:(Required)

Have you read the book "What To Do About Your Brain-Injured Child" by Glenn Doman?(Required)

If English is not your native language please indicate your degree of fluency:(Required)