Community Screening Registration, June 25, 2021
For children between 6 months and 5 years not currently enrolled in kindergarten.
Please provide the following information about your child. An appointment reminder will be sent 2-3 days prior to the event.
Email *
How did you hear about the Community Screening? *
By checking this box, I am giving permission to have my child screened. *
Required
Parent(s)/Legal Guardian(s) *
Mailing Address (Please include zip code) *
Phone numbers: Please list name then phone number. *
My child's full legal name is *
My child's date of birth is *
My child is a *
Who will be bringing your child to the screening? *
We live in __________ county *
Are there any custody issues or arrangements that we need to know about? If yes, please explain. *
Adult(s) this child lives with *
What is the primary language spoken in your home? *
My child was born *
I have concerns about my child's *
Does your child currently receive services through Early Steps? *
Does your child currently have an Individual Education Plan (IEP)? *
Please indicate the type of health insurance coverage you have. *
Name and address of pediatrician: *
Name other medical professionals this child has seen and the reason. *
A FDLRS Staff member will be reaching out to you shortly to confirm your child's information and schedule your appointment. If you have any questions you may call 850-561-6545.
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