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Child's First Name *

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Does your child have special needs?

Physical - Muscular Dystrophy, Multiple Sclerosis, Chronic Asthma, Epilepsy, etc.

Developmental - Down syndrome, autism, dyslexia, processing disorders

Behavioral/Emotional - ADD, Bipolarism, Oppositional Defiance Disorder

Sensory impaired - Blind, visually impaired, deaf, limited hearing

Other

Were you referred to us? If so, enter the Ambassador Name or Code here

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