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Kindy Form

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by

Full name of parent consenting to their child joining MotionMenders

Full name of child

Contact number

Email address of parent responsible for payments

Date of birth of child

Address

Kindy name

Class name

How often would you like your child to join our fun activities?

What services are you interested in? Do you have any specific physiotherapy goals?

Do you give consent to allow your child participating in the activities provided by MotionMenders?

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