Dr. Tracy Larson
Licensed Clinical Psychologist
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The information requested is necessary to determine a person's eligibility for various projects. Please feel free to contact us with any questions or concerns prior to signing up for our potential volunteer list.
Volunteer Participation Form
(people of all ages can participate)

Last Name:

First Name:

Gender:

Date of Birth:

Ethnicity:

Is this person in school?:

(Please indicate Current Grade or Highest Grade Completed):


Grade / Last Grade:

If under 25 years of age, parents' highest level of education:


Mother:

Father:

Has he/she been identified as having any of the following?
(Please mark all that apply):


 

Speech and/or Language
     Impairment

 

Autism/ Asperger's/ PDD

             

Mental Retardation or
     Developmental
     Delay                         

 

Learning Disability    


Hearing Impairment

 

Emotional or Behavioral
     Disturbance

 

ADHD / ADD

 

Orthopedic / Motor
     Impairment

 

Developmental Delay

 

Other - Please specify or Type:


Is he/she receiving special education services or SSI/SSDI benefits?:

Is he/she in a GiftedProgram?:

If under age 25, does he/she live with (or last lived with):

Parent/Guardian Name (if applicable):

Phone number (with area code):

Email address:



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