Early Childhood Screening Registration
Please complete this form prior to your early childhood screening appointment. If you have not done so already, click the following link to schedule your child's screening appointment.
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Email *
Parent/Guardian 1 *
First and last name
Phone number *
Parent/Guardian 1
Address (please include city, state and zip code) *
Parent/Guardian 1
Parent/Guardian 2 *
First and last name
Phone Number *
Parent/Guardian 2
Address (please include city, state and zip code)
Parent/Guardian 2– if different from Parent/Guardian 1 address
Child's legal name *
First, middle, last
Child's nickname or other name
Child's birth date *
MM
/
DD
/
YYYY
Child's sex
Clear selection
Child's Race/Ethnicity
Please choose the answer that applies to your child. *
Please complete the state race/ethnicity question below. American Indian: Person having origins in any of the original peoples of North America and maintains cultural identification through tribal affiliation or community recognition.
Instructions for Part A and Part B (please read carefully)
Please complete the federal race/ethnicity questions below. You may choose more than one answer in Part B.

The question for Part A is about ethnicity, not race. No matter what is selected in Part A, continue to answer the
question in Part B indicating the child’s race by marking one or more boxes.

American Indian or Alaska Native – Person having origins in any of the original peoples of North and South America
(including Central America), and who maintains tribal affiliation or community attachment.

Asian – Person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent
including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and
Vietnam.

Black or African American – Person having origins in any of the black racial groups of Africa.

Hispanic/Latino – A person of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture of origin,
regardless of race.

Native Hawaiian or Other Pacific Islander - Person having origins in any of the original peoples of Hawaii, Guam, Samoa or
other Pacific Islands.

White - Person having origins in any of the original peoples of Europe, the Middle East or North Africa.
Part A
The question for Part A is about ethnicity, not race. No matter what is selected in Part A, continue to answer the
question in Part B.
Is the Child Hispanic/Latino? *
Part B
The question for Part B is about race. No matter what you selected in Part A, continue to answer the
question in Part B, selecting all that apply.
What is your child's race? *
Choose all that apply.
Required
Primary/Secondary Language Information
Which language did your child learn first? *
Please specify.
Which language is most often spoken in your home? *
Please specify.
Which language does your child usually speak? *
Please specify.
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