New Participant Application
Child's fName:
School:
Childs lName:
Parents/Guardian:
Address:
Date Of Birth:
City:
Height:
State:
Weight:
Zip:
Grade:
Phone Number:
Date of App.:
Email:
Diagnosis:
Physical Functions:
(mobility, skills such as walking wheelchair use)
Psycho and Social Functions
(leisure interests, relationships-family structure, companion animals, fears/concerns
)
Goals:
(brief summary for current year)
Availability
Wednesday & Thursday 12-4:30. Saturday 9-12 & 12:30 to 4
Wed
Thur
Sat AM
Sat PM
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