REQUEST A PRE K SCREENING
REQUEST A SCREENING APPOINTMENT FOR DISTRICT 87 PRESCHOOL PLEASE TYPE IN ALL CAPS
DATE OF BIRTH FOR CHILD *
MM
/
DD
/
YYYY
DOES THE CHILD RECEIVE SPECIAL SERVICES FROM EARLY INTERVENTION (0-3) OR EARLY CHILDHOOD (3-5)? OR HAVE AN IEP? (INCLUDES SPEECH IEPS)
WHAT IS THE CHILD'S LEGAL LAST NAME? *
PLEASE USE THE CHILD'S NAME AS WRITTEN ON THE BIRTH CERTIFICATE
Your answer
WHAT IS THE CHILD'S LEGAL FIRST NAME? *
PLEASE USE THE CHILD'S NAME AS WRITTEN ON THE BIRTH CERTIFICATE
Your answer
WHAT IS THE PARENT'S FIRST NAME?
Your answer
WHAT IS THE PARENT'S LAST NAME?
Your answer
PHONE NUMBER *
Your answer
STREET ADDRESS *
Your answer
CITY
ZIP CODE
HOME SCHOOL (IF KNOWN)
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