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2. Parent First Name*
3. Parent Last Name*
5. Contact Phone Number*
7. Address1*
9. City*
10. State*
11. Zip*
13. Child Name*
14. Gender*
    -- Select One --FemaleMale
15. Date of Birth*
17. Are you the child's legal guardian?

    1. Parent
    2. Step Parent
    3. Foster Parent
    4. Grandparent
    5. Other Family Member
    6. Other
19. Does your child have Medicaid?
    -- Select One --yesno
21. Do you need an interpreter?
    Please specify language if necessary.
23. Child's Primary Physician
25. Information about your child
    Please indicate any concerns regarding your child's development, speech, hearing, vision, motor skills, or any other concerns you may have.
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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field