Help Me Grow Kent
118 Commerce Ave. SW
Suite 300
Grand Rapids, Michigan 49503

616-742-8903
www.helpmegrowkent.org



(put "0" if not premature)

For ASQ:SE-2™ English

For ASQ-3™ English

I have read the provided information about the Ages & Stages questionnaires, and I wish to have my child participate in the online screening program. I will fill out the questionnaire about my child's development and promptly submit the completed questionnaire through this Family Access online questionnaire completion system.

Kent County is providing the funding for services to the client through the Ready by Five Millage. To best meet you and your child's needs, Help Me Grow Kent County may be referring you to programs you are interested in.

By providing your consent you understand the following:

·       Help Me Grow Kent will collect demographic information about you and your child.

·       Help Me Grow Kent will have permission to share the information received during your participation in Ready by Five Early Childhood Millage funded services and make referrals. Your relevant data will be shared with the Kent County Health Department, First Steps Kent, and the organization(s) you agree to be referred to.

·       The individual information will only be given to the programs that you have said you wish to receive services from.

·       You are giving permission that will allow Help Me Grow Kent to receive updates on your and your child's status of services from programs where you have accepted services.

·       If in any follow-up phone calls or visits with a Help Me Grow Kent representative, you wish to receive additional services that are not accepted on today's date of signed consent, you agree that Help Me Grow Kent may make such referrals based upon your verbal consent.

·       Help Me Grow Kent is receiving funding by Kent County's Ready by Five Early Childhood Millage to provide this service. Your information will be shared with the Kent County Health Department and First Steps Kent so it can be used for the purposes of community reporting, program quality improvement, and program evaluation. All reports made publicly available to the community will contain only unnamed information about all children in general receiving a millage-funded service. Information specifically about you or your child individually will not be shared without your written permission.

You can cancel this consent form at any time by sending a cancellation request in writing to Help Me Grow Kent at the following address:

Attn: Help Me Grow

Kent Intermediate School District

1800 Leffingwell Ave NE

Grand Rapids, MI 49525

Please allow three (3) business days for the cancellation to take effect. This consent is valid until your child reaches six years of age.

Note: By clicking "Submit", you are agreeing to both our Family Access End User License Agreement and any other consent or authorization information outlined on this page.