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14
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1
Child Full Name
*
This field is required.
First Name
Last Name
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2
Your Full Name
*
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First Name
Last Name
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3
Today's Date
*
This field is required.
-
Date
Day
Month
Year
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4
Your Phone Number
*
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Contact Phone Number
Example: 01203473311
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5
Your Email
*
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example@example.com
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6
Relationship to Child
*
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Parent
Grandparent
Practitioner/Educator/Therapist
Other Family Member
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7
Contact Number
*
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Area Code
Phone Number
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8
Child Age
*
This field is required.
Age in Years Example: 8
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9
Location
*
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Home/school location
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10
Child's School
*
This field is required.
If none type "N/A"
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11
Child Date of Birth (DOB)
*
This field is required.
/
Date
Day
Month
Year
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12
Expected Start Date
*
This field is required.
School/Nursery expected start date
/
Date
Day
Month
Year
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13
I would be interested in the following services
*
This field is required.
Choose as many as you like
School Integration Teacher (SIT)/Shadow Teacher
Cairo Camps
North Coast Camp
El Gouna Camp
One-on-One at Sessions on the beach or at summer home
One-on-One Literacy and Numeracy Booster Sessions
Educational Baby-Sitting (EBS)
Group Classes (1 Practitioner to 5 Children)
One-on-One Relational Behavioural Modification; Social and Emotional Learning and/or Daily Life Skills (Supermarket; Mall; Club Sessions)
Parent Support Groups
One-on-One Parent Sessions
Family Psychotherapy
Speech Group Sessions
Speech one-on-one Sessions
Occupational Therapy Sessions
Sensory Integration Therapy Sessions
Other
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14
Please give us a small description about your current needs
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15
Urgency Level
1
2
3
4
5
Not Urgent at All
Very Urgent
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16
Unique ID
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