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Early Learning Center Birth through 3 Screening Request
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* Indicates required question
Email
*
Your email
Child's Legal Name (last, first, middle)
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Gender (check one)
*
Male
Female
Home language if other than English
Your answer
Primary/1st Parent/Legal Guardian Name (last, first)
*
Your answer
Relationship to the child:
*
Your answer
Home address (street address, city, state, zip code
*
Your answer
Do you have any concerns for your child?
*
Your answer
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