Legadel
681 Chestnut Ridge Rd. Spring Valley NY 10977
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Child First Name*
Child Last Name*
Date of Birth*
Address*
City*
State*
Zip*
Contact Information:
Phone*
Father Cell Phone*
Mother Cell Phone*
Email*
General information:
Father Name*
Mother Name*
Mother Maiden Name*
Which school did your child attend the last two years?
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1.
Last School Attend 1
2.
Last School Attend 2
Please provide two contact names and numbers for reference about your child. Name and phone number
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:
1)
Name
Number
2)
Name
Number
Please specify if your child is Yiddish or English speaking
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Does your child currently have any diagnosis? Please specify and attach all relevant reports. (Diagnosis, evaluations etc.)
Does your child currently benefit from any programs or services? Such as: OPWDD, ABA, OT, PT, Speech, Language, social, emotional, etc.) If yes, please specify:
Angency Name
Does your child have any allergies? If yes, please specify what, and the intensity of the reaction:
Is there anything specific you would like us to know about your child?
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