Leaping With No Bounds: Intake Form

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Leaping With No Bounds: Intake Form

Thank you for your interest in our Leaping with No Bounds program! Please answer the following questions so we can better serve your child:

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* Indicates required question

Email *

Your email

Your Full Name (Parent/Guardian) *

Your answer

Your Phone Number *

Your answer

Your Child's Name *

Your answer

Your Child's Age *

Your answer

Please describe:

... Your child's disability: *

Your answer

... How your child communicates:

Your answer

... The level of assistance your child needs with toileting:

Your answer

... Any relevant physical limitations your child may have: *

Your answer

... What upsets your child: *

Your answer

... What calms your child: *

Your answer

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