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We are always looking for children - with or without language problems - to take part in our studies. Please complete this form if you would like us to contact you next time we are recruiting participants. We will keep your details on file but they will not be divulged to any other agencies.

CONFIDENTIAL

Child's Name:

Parent/Guardian's Name:

Child's Date of Birth:

Address:

Telephone Number:

Email address:

Has your child been diagnosed as having a speech or language problem?

Yes No

If Yes, please give details:

Submit your details: