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How did you hear about us?

Parent/Guardian Name: Phone:

Cell: Work:

Street Address:

Email address:

Interested In:

Completing Sessions at ETL and/or Home Study

Reading Math Basics Express Quick Comp AdVocab

Irlen Screening Irlen Lenses/Contacts

Irlen Tint Check

1. Walking Age? Crawled for very long?

2. Frequent use of antibiotics as a child?

3. Right or left handed? Cursive or print handwriting?

4. Any damage at birth?

Additional Information/Notes: