Preschool Screening Interest Form
Preschool Screenings take place at the BHASED Administration office- 4670 11th St. East Moline, IL 61244.

To be eligible for a screening, your child must be AT least 34 months.
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Email *
What is the name of your child? (First and last) *
What is your child's date of birth? *
Date
What is your name? (First and last) *
What is your address (Street, City, Zip) *
What is the best number to reach you at? *
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