CIMT Camp Application
Child's name
First Name
Last Name
Age
Parent Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Diagnosis:
Does your child have allergies?
Please list/describe
Does your child require medications?
Please list/describe
Please describe your child's temperament or what a day in the life of your child is like:
Please upload a 10-30 second video of your child washing both hands.
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What goals do you have for your child during CIMT camp?
Does your child already have a constraint cast? If so, when was it created? Used regularly?
Will you need lodging during camp?
How did you hear about Reid Health CIMT camp?
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