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Special Needs Information Form

*First Name

*Last Name

*Email Address

*Phone Number

*Address Line 1

Address Line 2

*City

*State/Province/Region

*Zip/Postal Code

Please complete the questions below with the child’s information.

*Child/Young Adult Name:

*Child/Young Adult Date of Birth:

Child/Young Adult school if currently enrolled:

*Diagnosis:

*Dietary Restrictions or Allergies:

*Toilet Trained:

*Verbal?:

*Seizures?:

*Please list a couple tips that would be helpful for someone to know that is working with your child.

Siblings and birthdates:

*Please list a couple of favorite things that would be helpful for us to know. Examples: favorite candy, favorite drink, favorite place to go, etc.

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