Community Screening Registration, October 22, 2021

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For children between 6 months and 5 years not currently enrolled in kindergarten.
Please provide the following information about your child. An appointment reminder will be sent 2-3 days prior to the event.

Email *

How did you hear about the Community Screening? *

I am the legal guardian and give permission for my child to be screened. Please check the box. *

I give permission for my child to be screened.

Required

Parent(s)/Legal Guardian(s) *

Mailing Address (Please include zip code) *

Phone numbers: Please list name then phone number. *

My child's full legal name is *

My child's date of birth is *

My child is a *

Please list ages of siblings in the home. *

Who will be bringing your child to the screening? Please list name and relationship to child. *

We live in __________ county *

Are there any custody issues or arrangements that we need to know about? If yes, please explain. *

Adult(s) this child lives with *

What is the primary language spoken in your home? *

My child was born *

I have concerns about my child's *

Does your child currently receive services through Early Steps? *

Yes

Does your child currently have an Individual Education Plan (IEP)? *

Yes

Please indicate the type of health insurance coverage you have. *

Name and address of pediatrician: *

Name other medical professionals your child has seen and the reason. *

I am the legal guardian and give my absolute right and permission to use my child's photograph and my photograph in promotional materials and publicity efforts. I understand that the photograph(s) may be used in publication, print ad, direct-mail piece, and electronic media or other forms of promotion. I release the screening staff, photographers, their offices, employees, agents, and designees from liability for any violation of any personal or proprietary right I may have in connection with use. I am 18 years of age or older. *

Yes

I understand that wearing a mask will be required during the screening event. *

Yes

Required

A FDLRS Staff member will be reaching out to you shortly to confirm your child's information and schedule your appointment. If you have any questions you may call 850-561-6545.

Send me a copy of my responses.

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