Special Needs Recreation and Leisure Survey

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1. Participant Gender:

Participant Gender:

2. Participant Date of Birth:

Participant Date of Birth:

3. Name of School Participant attends:

Name of School Participant attends:

4. Where do you live?

Where do you live?   City of Fort Myers City of Bonita City of Fort Myers Beach Estero/South Fort Myers Lehigh North Fort Myers Matlacha/Pine Island Sanibel/Captiva East Fort Myers/Alva City of Cape

Other (please specify)