Count Your Kid In Sign-up
Please provide the following information in order to reserve your child's spot for the upcoming Count Your Kid In screening.
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Email *
Parent/Guardian's name *
Child's name *
Child's date of birth *
Date
Child's Address *
If parent's address is different, please provide parent's address.
Phone number *
Do you have concerns with your child's development.  *
If you indicated concerns, please describe them below.
What language did your child first learn to speak/use? *
What language does your child most often speak/use? *
What is your preferred language? *
What day do you prefer for your child's screening? *
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