MtFFC Consent
Dear Parent/Guardian,

Thank you again for participating in Make the First Five Count (MtFFC) free child development screening and monitoring program.  We are excited to be partnering with you to celebrate your child's developmental milestones, and support you in anyway we can.  Please complete and return this consent form below to continue with the rest of the screening process.

You can view and download our HIPAA Privacy Statement:
https://www.easterseals.com/esep/who-we-are/hipaaprivacy/

Please feel free to contact us if you have any questions or concerns.

With Regards,

Melissa Vandever                                                                                                                                                  
Child Development Specialist                                                                                                    
Easterseals Eastern PA-Lehigh Valley                                                                                                  
www.easterseals.com/esep                                                           
c-mvandever@esep.org                                                                                                                             
P: 610-289-0114 x230                                                                                                                                      

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Child's Name *
School/Organization (if applicable)
Date of Birth *
MM
/
DD
/
YYYY
Full Address *
County Child Resides in *
Parent/Caregiver's Name *
Parent/Caregiver's Number
If the number above is a cell, are you ok receiving text messages on occasion from the MtFFC? *
(We would only share up coming screening links and reminders.)
Parent/Caregiver's Email *
Language Family mostly uses *
Does your child receive any therapy? *
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