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Melrose-Mindoro Child Development Days
Calling all Children Birth to 5 years Old!  The screening will take place at Melrose Mindoro Elementary in the Yellow Hallway on March 14 from 1 pm to 7 pm and March 15 from 8 am to noon.

After completion of this form and the Ages and Stages (ASQ) developmental questionnaire someone from the school will contact you with your assigned screening time.

Pre-registration for a time slot is required.
If you have any questions, please call 608-488-2201.

Once you have completed the form, please go to the following website to compete the screening.  At the end when it asks for an email to email the results, please send it to jones.kathryn@mel-min.k12.wi.us.

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Email *
What is your student's name (first and last name as it appears on their birth certificate)?

If you have another child, you can add their information below.
 *
Birth Date *
MM
/
DD
/
YYYY
What is the address of the student? *
What is the parents' or guardian's name? *
What is a good phone number to contact you at? *
Rank the times in order of preferences with 1 being first choice and 5 being last choice. *
Choice 1
Choice 2
Choice 3
Choice 4
Choice 5
March 14 1 to 3 pm
March 14 3 to 5 pm
March 14 5 to 7 pm
March 15 8 am to 10 am
March 15 10 am to noon
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