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Precautions & Contraindications
Prospective Participant Name
DOB
Height
Weight
Street Address
City, State, Zip Code
Doctor Name
Doctor Phone Number
Behavior Concerns (i.e. elopement, aggression)
Please describe mobility level/needs. Do they require support while sitting?
Health Concerns/Diagnoses (i.e. hemophilia, seizures, Down Syndrome, implanted devices)
Is Axial Skeleton closed? (for Down Syndrome only)
Date of Last Seizure (if applicable)
Contact Name
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Contact Email
Relationship to Participant
In Case of Emergency Call
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What outcomes are you hoping will result from time at Stir-n-Up Hope?
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