Children & Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)

Special Event Questionnaire

Certificate of Insurance Request Form

For expedited service, fill out the form below. If you prefer to download, fill out, and fax a PDF form INSTEAD of filling out this form, click here.

• Denotes required field.

  • Date Format: MM slash DD slash YYYY
  • If YES, please forward a copy of the document with this request form.
  • If NO, certificate will be mailed to your chapter for you to forward.
  • This field is for validation purposes and should be left unchanged.