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First Name: *
Last Name: *
Address: *
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Email: *
Child's First Name: *
Child's Last Name: *
Child's Date of Birth: *
Current School: *
Current Grade: *
Who Recommended Gateway:
Has your child received a psycho-educational or neuro-psychological evaluation within the previous 18 months indicating a language or perceptually based learning disability?: *
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If yes, please explain: