Community HELP Application

Application for Community HELP Students

Student Information

Name(Required)
MM slash DD slash YYYY
Check Box if Home Schooled
Parent/Guradian Name(Required)
Address(Required)
Parent/Guradian Name (opt)

Diagnostic Information

MM slash DD slash YYYY
Please check the diagnosis(es) you have received that makes you eligible for our services:(Required)

Confirmation

Please check your preference of contact:(Required)
Disclaimer(Required)

H.E.L.P. Contact and Updates

Contact Us

Marshall University HELP Program
520 18th St.
Huntington, WV 25703

What’s New

For more information:

Name(Required)
I would like more information about the following area(s):(Required)