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Name of Parent or Guardian *
Phone or Email *
First name of child *
Is the child on any prescription medication? *
Does the child have any history of mental illness or learning disability? *
Does the child speak more than one language at home?
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 | firstname.lastname@example.org
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