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* 1. Student's Full Name

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* 2. Name of Parent or Guardian completing form

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* 3. Student's Date of Birth

Date

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* 4. Student's Age

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* 6. Student's School

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* 10. If Student was retained, what was the reason given?

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* 12. If the Student has been diagnosed with a specific learning disorder, which disorder?

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* 17. What would you like help with? (Check all that apply)

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* 18. What is your primary contact number?

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* 19. What is your email address?

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* 20. What is your physical address?

0 of 21 answered
 

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