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* 1. DISCLAIMER: By submitting an entry to Jiraffe, Your Story, you give Jiraffe permission to publish information across the Jiraffe and Jenx communication channels.

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* 3. First Name:

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* 4. Last Name:

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* 5. Address;  where we will send out your exclusive cuddly Jiraffe mascot.

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* 6. Email Address:

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* 8. Child's Name:

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* 9. Child's Clinical Diagnosis e.g. Cerebral Palsy, Spina Bifida

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* 10. Child's History (Surgery, equipment currently using)

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* 11. Benefits of using Jiraffe products (Medical, Emotional, Practical, Family life)

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* 12. Your reasons for choosing a Jiraffe product:

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* 13. Here at Jiraffe, customer opinion and satisfaction is paramount. We really value your opinion of our products and service, so if there is anything that you think that we could do better, please let us know. Similarly, if you’ve had a great experience, we’d also love to hear.

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* 14. Let's keep in touch...Would you like to receive Jiraffe email updates focused around products, competitions and clinical research? By confirming 'Yes', you agree to be included on a distribution list to receive marketing updates from Jiraffe, which you can unsubscribe from at any point in the future.

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