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CITY: STATE: OH GRADE: ZIP: REEVALUATION DATES DATE OF MEETING: DATE OF BIRTH: DATE OF LAST ETR: DISTRICT OF RESIDENCE: REFERRAL DATE: DISTRICT OF SERVICE: DATE PARENTS CONSENT RECEIVED: PARENTS'/GUARDIAN INFORMATION NAME: ETR FORM STATUS STREET: CITY: STATE: OH HOME PHONE: WORK PHONE: CELL PHONE: PART 1: INDIVIDUAL EVALUATOR'S ASSESSMENT (Separate Assessment from each Evaluator) PART 2: TEAM SUMMARY EMAIL: ZIP: PART 3: DOCUMENTATION FOR DETERMINING THE EXISTENCE OF A SPECIFIC.

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