EmailMeForm
What's your name?
*
First
Last
What's your email?
*
Does your child enjoy physical activity?
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Yes
No, but open to the idea of physical activity
No, they absolutely hate the idea of physical activity
Has your child ever received a diagnosis? (e.g. ADHD, ASD etc.)
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Yes
No
NOTE: This is just to let us know how we can cater to your child.
What is your child's gender?
*
Male
Female
Why would you like your child to do the CounterPunch program?
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What do you hope for your child to achieve through CounterPunch?
*
Which suburb and state are you based? (e.g. Mt. Barker, SA)
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What's the best phone number for us to jump on a call?
*
