Developmental Screening Day- FRC- Littleton

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Join us:

Where: Family Resource Center Suite 312, 241 Main St. Littleton, NH.

When: Thursday, April 10th from 9am–3pm

Ages: Infants/Children Ages 1 month- 5.5 years of age

Cost: Free

Email *

Has your child been identified as a child in need and is currently receiving services/supports from early intervention (FCESS), infant mental health (IMH), or school district based services? *

Yes

If you answered "Yes" to the above question, registration for this event is not indicated, and you do not have to move forward with this form. If interested, you are welcome to come in at any time to get your child's vision/hearing screened and receive valuable resources. *

I acknowledge this statement- and my child is not currently receiving services elsewhere- and I will proceed with this registration form.

I acknowledge this statement, and though my child is receiving services, I am still interested in the vision/hearing screening portion and will drop in anytime between 9am-3 pm

Name of Parent/Caregiver/Guardian:

Town of Residence:

Phone/Text Number:

Age of Child # 1 in months (i.e. 14 months)

Age of Child # 2 in months (i.e. 36 months)

Age of Child# 3 in months

Times:

Column 1

9:00-9:30

9:30-10:00

10:00-10:30

10:30-11:00

11:00-11:30

11:30-12:00

1:00-1:30

1:30-2:00

2:00-2:30

2:30-3:00

Clear selection

I understand that by taking part in the developmental screening, you’re helping us gather important information that will be used in a general way, without identifying any child personally. This information will only be used to help improve services for all children, ensuring they get the best support possible.

Yes, I agree

No, I don't agree

Clear selection

Please contact me with suggestions for follow up activities and/or actions if my child's ASQ score is in the monitoring zone or below typical development.

Yes

Clear selection

Submit

Clear form

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