Interest Form Name of child? * First Name Last Name Birthdate * Child's gender How did you hear about MMS? Name and email of parent 1 * Name and email of parent 2 Address * Who lives in the house with your child? * Is your child currently attending school? If so, which one? * Please list any childhood illnesses including duration, severity and age that they occured * Please describe your child's weekly screen exposure including type of device, days of the week and hours spent * Describe where your child is with toilet awareness and independence * Is your child currently breastfeeding? * Please list any known allergies and/or dietary specifications * Comments Thank you!
