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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
Contact Phone
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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