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Learning2Listen
Learning2Listen
Learning2Listen
Learning2Listen
Impacts on Sport, Music and Dance
Learning2Listen
Learning2Listen
Learning2Listen
Learning2Listen
Learning2Listen
Learning2Listen
Learning2Listen
Learning2Listen
Learning2Listen

 

Information Form

Last name ..................................................
First name ..................................................
Sex...............................................................
Date of birth..................................................
Age................................................................
Address........................................................
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.......................................................................
Telephone #................................................
Cell #............................................................
School.........................................................
Teacher.......................................................
Email.......................................................
Previous Assessments
Type Practitioner Date
......................................................................
......................................................................
......................................................................
......................................................................
Current Therapies
Type Practitioner Tel No.
......................................................................
......................................................................
......................................................................
......................................................................
Fathers Name.................................................
Fathers Home Tel #...........................................
Fathers Work Tel #...........................................
Fathers Cell #...............................................
Fathers Home Address.........................................
.............................................................
Mothers Name.................................................
Mothers Home Tel #...........................................
Mothers Work Tel #...........................................
Mothers Cell #...............................................
Mothers Home Address.........................................
Married/Divorced/ Single (please circle correct information)
Name of person responsible for payment.......................
REFERRED BY..................................................

COPY, PASTE AND PRINT
Then fill in the forms
Send together with checklist to
Head Office
Khymberleigh Herwill-Levin
Learning to Listen - THE BRAIN FITNESS CENTER
P.O. Box 1557
Zephyr Cove
NV, 89448

SERVICES ARE PAID FOR AT BEGINNING OF THE TRAINING

CASH, CHECK AND CREDIT CARDS ARE WELCOME


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Learning to Listen
THE BRAIN FITNESS LEARNING CENTER

(213) 399 1708

ait1st@yahoo.com 

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CANADA HEAD OFFICE
(604) 264 9026
(604) 716 6209

www.ait2listen.com

  info@ait2listen.com

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Canadian Office

Associated with the following

Learning to Listen -
THE BRAIN FITNESS LEARNING CENTER, USA

California, Nevada, Arizona, Oregon

Learning to Listen International

Dr. Stan and Karon Shear, Canada

ARI - USA

Israel, South Africa, Hong Kong

 

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