Survey

If you as the parent are interested in your child participating in summer groups through the Kid Clinic please fill out the following survey for any children age 4-18.

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* 1. Contact Information

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* 2. Name of Child 1

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* 3. Age of Child 1

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* 4. Issue or behavior needing addressed for Child 1

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* 5. Name of Child 2

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* 6. Age of Child 2

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* 7. Issue or behavior needing addressed for Child 2

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* 8. Name of Child 3

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* 9. Age of Child 3

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* 10. Issue or behavior needing addressed for Child 3

0 of 10 answered
 

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