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Name of Parent or Guardian *
Phone or Email *
First name of child *
Birthdate *
Sex * Male Female
Is the child on any prescription medication? * Yes No
Does the child have any history of mental illness or learning disability? * Yes No
Race/Ethnicity
Caucasian African American
Asian Native American
Hispanic Mixed/Other
Does the child speak more than one language at home? Yes No If so, what language(s)?
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Dr. Francys Subiaul | Assistant Professor of Speech and Hearing Science Mind, Brain & Evolution Center| The George Washington University 2115 G Street, NW #204 | Washington, DC 20052 202-994-7208 | subiaul@gwu.edu
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