Interest Form

Filling out this form does not oblige you or your child to apply or participate in Adelphi’s Social Training Center. The purpose of this form is merely a point of contact for us to reach out to you closer to the start of the program.

Your First Name:
Last Name:
Child's First Name:
Child's Age:
Address Line 1:
Address Line 2:
State:
ZIP Code:
Home Number:
Cell Number:
Email:
Spectrum Disorder:
Comments

To find out more about our high functioning autism support center services, please contact:

The Social Training Center
Gordon F. Derner Institute
Hy Weinberg Center, Room 112, Garden City, NY 11530
p - 516.237.8579
f

- 516.877.4754
e - socialcenter@adelphi.edu

This page was last modified on January 7, 2011.

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Interest Form