Helping Kids with Hemiplegia CIMT Camp Application Questionnaire 2017
Welcome to Helping Kids with Hemiplegia! Please take a moment to fill out this form and submit it to us for your camper. This completed Camp Application Questionnaire and a Prescription for an OT Evaluation is required to complete your child's application. Applications are due by 5 p.m. EST on March 22, 2017. Thanks!
If you have any questions please email us at
Email address
Untitled Title
Child's Name and date of birth (month/day/year)
Your answer
Parent/Guardian Name
Your answer
Address - Street, City, State, Zip Code
Your answer
Cell Phone
Your answer
Home Phone
Your answer
Preferred method of communication (click all that apply)
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms