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Pre-K Screening - Registration
Email address *
Student Name *
Your answer
Birthdate *
*Child must be 3 years old on or before screening date
MM
/
DD
/
YYYY
Child's Gender *
Do you have any concerns about your child?
Your answer
Parent #1 Full Name *
Your answer
Parent #1 Phone Number *
Your answer
Email Address *
Your answer
Parent #2 Full Name
Your answer
Parent #2 Phone Number
Your answer
Street Address
Your answer
City/Zip Code *
Your answer
Preferred Screening Time
Best person to contact to set up screening time
Name/Phone Number
Your answer
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