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Nded? Please specify YES NO HEARING Is there a defect in hearing? YES NO If yes, please specify. SPEECH Is there a defect in speech If so: Severe Moderate Mild INTELLECT Do you consider the child mentally normal? YES If No, indicate: Moderately mentally retarded (50-80 I.Q) severely mentally handicapped (30-50 I.Q) Are there signs of Down's Syndrome? Do D you consider the applicant a suitable candidate f id h li i bl did for: (Pl (Please i di indicate b l below with X) i h a) Sch.

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