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Parent's Info
Parent's First Name (required)
Parent's Last Name
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Child's Info
Child's first name
Child's last name
Child's gender
Child's date of birth
Primary language spoken to child
Other language(s) spoken to child (e.g. “10% French”)
Multiple birth? (if yes, please specify type)
If child was born early, please specify due date
Any cognitive, language, or physical deficits?
Siblings? (If any, specify gender and birth date)
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