Screening Request Form
Please fill out this form to request a screening for your child. Our programs serve 3- and 4-year-old students within the Collinsville Community Unit 10 School District.
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电子邮件地址 *
Date of request *
年
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月
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日
Child's Name (first, middle, last) *
Child's date of birth *
年
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月
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日
Gender *
Parent's name(s) *
Phone Number *
What is your child's primary language? *
必填
Is there another language spoken in the home? If so, what language(s)? *
Street Address *
City *
Do you own or rent your residence, or are you living with others? *
Please describe any concerns you have for your child's development or learning: *
Is this child in foster care? *
Has DCFS been involved with your family in the past year? *
Did your child receive Early Intervention Services from birth to 3? *
Do you receive TANF benefits (short-term cash assistance)? *
Does your child attend Head Start? *
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