Event registration
Event Dates/Times: March 23rd from 1pm-4pm   AND  March 24th from 1pm-4pm
Event Address: Danville (you will receive the address via an email upon confirmation of completed event registration)
Contact us at:  exceptionaldating@gmail.com
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Name *
Gender *
Age *
Understanding that this workshop is for people that are neurodivergent and/or have special needs, do you have a diagnosis that you are willing to share? *
Phone number with area code *
Email *
Finish the sentence 
I am looking for...
 *
Are you willing to share your information (phone number and email address) with the other participants in the workshop.  If yes, please know that you may be contacted by a participant at a later time to further a potential connection. *
How interested are you in dating? *
Required
Have you ever been on a date or had a relationship? *
Do you chat with people online? *
Have you ever been on a dating app? *
Do you have a driver's license?  *
Who lives at home with you? *
How do you plan on getting to and from the workshop? *
Emergency Contact that can drive
Name:
Relation:
Phone Number:
 *
I understand that I will have to pay $249 once I get a submission email from Jeff and/or Kara confirming registration for the workshop *
Required
Allergic to anything? *
Are you comfortable having photos taken of you for the purpose of advertising? *
Please feel free to share any additional information about yourself that you would like us to know.  Also, if there are any additional needs that we should be aware of please let us know. Ex.  a seizure plan that we should have a copy of while you are in the sessions. *
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