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*
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Child First Name
*
Child Last Name
*
Child's Gender
*
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Child's Date Of Birth
*
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A Free Bird Program(s) You Are Interested In
*
Dream Big
Fly Free
Take Flight
Preferred Language (If Not English)
Days You're Available During
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Availability Start
*
---------
8AM
9AM
10AM
11AM
12PM
1PM
2PM
3PM
4PM
5PM
6PM
7PM
8PM
Availability End
*
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8AM
9AM
10AM
11AM
12PM
1PM
2PM
3PM
4PM
5PM
6PM
7PM
8PM
Child's School Name
*
Art Form The Child Is Interested In
*
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Acting
Creative Writing
Culinary Arts
Dance
Drawing or Painting
Martial Arts
Music
Photography
Other
Child's Experience In The Art Form
*
Beginner
Intermediate
Advanced
Child's Diagnosis
*
Child's Age At The Time Of Diagnosis
*
In Or Out Patient
*
Inpatient
Outpatient
Neither
Would You Prefer Tutoring At Your Home Or In The Hospital?
*
At My Home
In The Hospital
Any Medical Precautions We Need To Be Aware Of?
Does Your Child Require Medications?
If Yes, Please Elaborate
Does Your Child Have Any Allergies?
If Yes, Please Elaborate
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