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Parents Name


Your Email


Diagnosis (inc hospital and diagnosis date)


Do you Live in the UK? If YES, Check the box and enter your address below.


Yes




Childs Name


Childs Age


Hair Type/Colour


Skin/Colour


Specific physical characteristics (eg wheelchair user, glasses etc)


Specific character, eg. Superman, Cinderella, Sporting) Or Other Character Type


Favourite Colours




Does you child have any siblings? If YES, Check the box and enter details below.

Yes