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Do you have permission to register this child in speech or language camp?
I am the child's parent or legal guardian. *
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What is the child's name?
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What is the child's DOB?
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What is the name of the parent or legal guardian?
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What is the home phone number?
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What is the child's home address?
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What is the parent's email address?
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What is the parent's cell phone number?
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When is the best time to reach the parents?
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Which week will the child be attending camp?
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What is the child's payment source for services?
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If private insurance, who is your insurance carrier?
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What is your child's
T--shirt Size:
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What are your concerns regarding your child's speech and language skills?
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Are there any special considerations regarding your child?
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