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 helpingkids.unc@gmail.org.
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)
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