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CHILD/FAMILY RECORD SHEET
Child's name:
Child's age/DOB:
Date diagnosed:
Parent's name/s:
Address:
Phone number:
Email:
Siblings names/Ages:
(re social activities/events)
School attended:
Are you interested in the Butterflies support group
1. No
2. Yes
(as a helper /committee member)
3. Yes
(but only to attend educational presentations/social activities)
If Yes to Number 2 or 3 what issues/concerns would you like addressed in presentations and what social activities might you be interested in attending?
Educational presentations:
Social activities:

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