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Student Name
Please check the YES boxes if you agree that the statements are correct. If the statements are not correct, check the NO boxes. When you have finished, please sign your name and date.
YES _____ NO _____ I have been notified that my child has been identified and qualifies for placement into the dyslexic program.
YES _____ NO _____ I give permission for my child to be placed into the dyslexic program.
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Signature of Parent or Guardian
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Date