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Children’s Pill Swallowing Workshop
Children's Pill Swallowing Workshop Form
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Child Information
Child's Name
*
First
Last
Child's Preferred Name / Nickname
*
Child's Age
*
Date of Birth
*
MM slash DD slash YYYY
Grade in School
*
Parent / Guardian Information
Parent / Guardian Name
*
First
Last
Relationship to Child
*
Phone Number
*
Email Address
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Preferred Method of Contact
*
Phone Number
Email Address
Screening Questions
Medical & Safety Questions
Has your child ever swallowed a pill before?
*
Yes
No
Sometimes
Does your child currently take any medications?
*
Yes
No
If yes:
Liquid medication only
Pills / Capsules
Both
Has your child had difficulty with:
Gagging
Choking fears
Texture sensitivity
Anxiety around medication
Vomiting with medication
Difficulty swallowing foods
Sensory sensitivities
Does your child have any diagnosed conditions that may affect swallowing?
ADHD
Autism
Anxiety
ARFID
Oral motor difficulties
Feeding disorder
Gl condition
None
Has a physician ever told your child not to swallow pills?
*
Yes
No
Does your child have food allergies or dietary restrictions?
*
Yes
No
If yes, please explain:
Consent
*
I agree.
Registration for the Children’s Pill Swallowing Workshop is only confirmed once the full $50 payment has been received. Space is limited to 15 participants and spots will be filled on a first-come, first-served basis.
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Total
Credit Card
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