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Parent/Guardian or Adult in need of services: *

First Name

Last Name

Child/Dependent:

Complete the following about the individual for which you would like servic.es

First Name

Last Name

Date of Birth *

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DD

YYYY

Address *

Address 1

Address 2

City

State/Province

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ARK Service(s) of Interest *

Educational Evaluation

Instruction

Dyslexia Screening

Gifted Testing

Teacher Trainings

Other