Child Find Pre-K Screening Registration
Please provide the following information about your child. Thank you!
* Required
Email address
*
Your email
Does your child currently receives services through Early Steps?
*
Choose
Yes; Note: Your child has already been screened. Please contact Early Steps with concerns.
No
Does your child have an Individual Education Plan (IEP)?
*
Choose
Yes; Note: Your child has already been screened. Please contact your child's school with concerns.
No
Mother's First Name
*
Your answer
Mother's Last Name
*
Your answer
Father's First Name
*
Your answer
Father's Last Name
*
Your answer
Guardian's First Name
*
Your answer
Guardian's Last Name
*
Your answer
Additional Adult First Name
*
Your answer
Additional Adult Last Name
*
Your answer
Adult(s) this child lives with
*
Choose
Mother Only
Father Only
Both Mother and Father
Grandparents
Shares time with mother and father in two homes
Special Circumstances
Are there any custody issues or arrangements that we need to know about? If yes, please explain.
*
Your answer
Mailing Address
*
Your answer
Phone numbers: Please list name then phone number.
*
Your answer
Would you like a reminder text message or email?
*
Choose
Text Message
Email
Both Text and Email
We live in __________ county
*
Choose
Gadsden
Jefferson
Leon
Taylor
Wakulla
My child's full legal name is
*
Your answer
My child's date of birth is
*
Your answer
My child is a
*
Choose
Female
Male
My child's ethnicity is
*
Choose
Hispanic
Non Hispanic
Caucasian
African American
Asian
Mulitracial
Other
What languages are spoken in your home?
*
Choose
English
Spanish
Something Different
My child was born
*
Choose
Full term (38 weeks or more) with no complications
Full term (38 weeks or more) with complications or NICU stay
Premature (37 weeks or less) with no complications
Premature (37 weeks or less) with complications or NICU stay
Birth History is Unknown
My child currently attends
*
Choose
Does not attend/ stays at home with parent or caregiver
Daycare/ child care
Private school
Head Start
Voluntary Prekindergarten (VPK) at a private center/preschool/charter school
Voluntary Prekindergarten (VPK) at a public school
My child has been asked to leave from the school they attended
I have concerns about my child's
*
Vision
Hearing
Speech/Language
Behavior/Social- Emotional
Development
Required
Send me a copy of my responses.
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