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Special Friends Intake Form
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Form Entry
Child's Name
Date of Birth
Primary Contact's Name
Relationship to Child
Phone Number
Primary Diagnosis
Autism
Visually Impaired/Blind
Cerebral Palsy
Seizure Disorder
Developmental Delays
Down Syndrome
Head Injury/Spinal Cord
Hearing Impaired/Deaf
Other
Mental Disability
Mild
Moderate
Severe
Profound
Medical Information
Allergy Information
Sensitivities
Large Groups
SociaI/Emotional Information
Personality
Favorite Activities
Angry or Frustrated Behavior
Calming Interventions
Large Group or Playground Challenges
Additional Information
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