FDLRS NEFEC Child Find Screening Registration

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Please provide the following information about your child. Thank you!

*Required

Email *

Untitled Title

My child's full legal name (first, middle, last) is: * *

My child is a: * *

Female

Male

My child's date of birth: *

My child's race is:* *

Caucasian

African American

Asian

Native American/Alaskan Native

Pacific Islander

My child's ethnicity is: * *

Hispanic

Not Hispanic

What language(s) are spoken in the home?* *

English

Spanish

Other:

Has your child ever received any of the following services? *

Past-More than 1 year ago

Past-Less than 1 year ago

Currently receives

Never/Not applicable

Speech/Language Therapy

Occupational Therapy

Physical Therapy

Behavior (ABA) Therapy

Counseling

Early Steps (birth to 3rd birthday)

My child currently attends _______________. *

Voluntary Prekindergarten (VPK) in a public school

Voluntary Prekindergarten (VPK) at a private center/preschool/charter school

Head Start

private preschool

daycare / child care

Doesn't attend / Stays home with parent/guardian

Other:

Name of preschool:

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