ADHD, ASC & LD Belgium Membership Form
2017 - 2018
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ADHD, ASC & LD Belgium, Rue Washington straat 40,               1050 Brussels / Belgium
Please complete this form online if possible - or print, scan & email to info@adhd-edu.be
Family Name(s) *
First Name: *
Full Address (inc. postcode & city) :   *
Email : *
Phone number (house and/or GSM) :   *
Type of Membership (February 2018 - summer 2018) *
*Profession or Name of School or Organization (Up to 10 people from an organization or school can attend each event at the reduced member price) - write "family" if it doesn't apply *
How did you hear about us?
Please pay the required membership fee into our bank account as follows and send us a proof of payments to info@adhd-edu.be :   001-5695038-50    or   IBAN: BE86 0015 6950 3850    // BIC:  GEBABEBB  // Membership 2017-18 + your name
Benefits of Membership:
- Free or reduced-price entry to all of our workshops and conferences
- Access to Library books at Parent Support Meetings and in our office
- Reduced-price coaching for children, adolescents, parents, and teachers
- Free assessment of special needs of children and adolescents

If you experience technical problems, please contact us at info@adhd-edu.be and we will send you the form by email.

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