LEADERSHIP GYM APPLICATION

*Fillable Application is listed beneath the flyer/image.

Parent/Caregiver Complete FIRST and LAST NAME (required)

Email(required)

Phone (required)

How did you hear about the LEADERSHIP GYM?

Child/Children (required) – Names, Ages, chronic or complex disability / health condition(s)

ADDRESS with COUNTY (required) – for example – 1234 Green Drive, Greenville, AR 55555 Doe County

Leadership or Advocacy Experience – List up to three (3) experiences.

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Arkansas Disability Coalition • PO Box 31420 • Little Rock, AR 72260
501-614-7020 • Email: info@ardisabilitycoalition.org

Thank you for your generous donation to our organization.

We are making a difference in the lives of families with disabilities in Arkansas. Donate Here