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Application Form
Kids With Courage
Parents name
First name
Last name
Address
Address line 1
Address line 2
Address line 3
Address line 4
Town/Suburb
City
Postcode/Zip
Home phone
Cell phone
Email address
Child's name (s)
First name
Last name
Gender
Male
Female
School
School Year
Date of Birth
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In your opinion, what are your child's main interests?
What are your child's main strengths?
What major concerns do you have about your child?
In your opinion, what ideas could be implemented to improve or overcome this?
Do you have any other relevant information you think is important for us to know?
Has your child received any individual counselling?
Yes
No
Please list any food allergies?
Is your child on any medication?
Yes
No
If yes, please provide details
Other Comments
How did you hear about this course
Cost
$50.00
$50.00
Pay method
Internet Banking
Make deposit to account
03 0887 0281519 00
Cash
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