Pilot for a Day (P4D)Questionnaire
The more detail you can share with us the better your child's experience will be.
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Full Name of Child: *
Preferred Name or Nickname. *
Date of Birth: *
MM
/
DD
/
YYYY
Age: *
Shirt Size? *
Pants Size? *
Height / Weight? *
Medical Condition: (Please tell us a little bit about your child's condition: their diagnosis, when it began, currently in treatment?, etc) *
Interests/Hobbies: *
Favorite Food: *
Favorite Movie: *
Favorite Sports Team: *
Favorite Actor/Singer: *
School (Name/Address/Phone): *
Does your child own an iPad? *
Are there any physical or mental limitations we should be aware about? (limited ability to stand or walk, tires easily, confined to wheel chair, doesn't like loud noises, etc) *
Provide us with any additional information that you would like to share about your child:
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