Community Screening Registration
For children between 6 months and 5 years not currently enrolled in kindergarten.
Please provide the following information about your child. Thank you!
Email address *
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 *
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
Please let us know what is the best time to be reached: *
Would you like a reminder text message or email? *
We live in __________ county *
My child's full legal name is *
Your answer
My child's date of birth is *
Your answer
My child is a *
My child's ethnicity is *
What languages are spoken in your home? *
My child was born *
My child currently attends *
Does your child currently receives services through Early Steps? *
Does your child have an Individual Education Plan (IEP)? *
I have concerns about my child's *
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 850-561-6547 or 850-561-6545
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