Please fill in your information below.

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* 1. What is your name?

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* 2. Your email address

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* 3. What is the child's NHI number?

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* 4. What is the child's full first name?

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* 5. What is the child's last name?

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* 6. Choose gender

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* 7. What is the child's date of birth?

Date

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* 8. Ethnicity

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* 9. Child's address

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* 10. Name of parents/guardians

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* 11. Phone number of parents/guardians

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* 12. Mobile phone number

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* 13. Email address of parents

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* 14. What diagnosis has the child received?

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* 15. Who made the diagnosis?

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* 16. Where was the diagnosis made?

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* 17. When was the diagnosis made?

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* 18. Provide the names of up to 2 adults interested in participating

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* 19. I confirm the child is between 11- 16 years of age

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