Wufoo
Hosting Week 3
Your Name
First
Last
Child's Name
First
Last
Child's Sex
Male
Female
Child's Birthdate
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MM
/
DD
YYYY
How would you describe the child's personality?
What, if anything, has changed regarding your description of the child from previous descriptions.
Have there been any changes in the child's interaction with your family?
Have there been any changes in the child's interaction with others?
What new experiences has your child had this week? Any new activities/interests?
How would you describe the child's emotional state at this point?
From your experiences, does the child have any medical, psychological or other issues that need to be better understood?
What problems have you had with the child, and have any new problems developed?
How has the child's visit affected your family?
Child's current weight
Are there any concerns about this child you would like to discuss with a New Horizons for Children hosting representative
If so, please provide a phone number and best time to reach you at that number.
Please upload 2 photos
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