Child Date of Birth
Format: yyyy-mm-dd
Child DOB you entered is in the future, are you sure of that? (Please correct the date before proceeding to the next step). Please enter your child's DOB and not the screening date or today's date (Please correct the date before proceeding to the next step). Child DOB you entered is not valid, please format the date like this: YYYY-MM-DD

Weeks Premature
(put "0" if not premature)

For ASQ-3™ English

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

I authorize the Early Learning Coalition of Florida's Gateway (ELC-FG), Inc. and/or staff at contracted School Readiness (SR) and/or Voluntary Prekindergarten Program (VPK) sites to administer screenings and/or assessments for my child/children.  I certify that I am the parent or guardian of this child.  I understand that I will be informed of all results from these screenings and/or assessments.  I also understand that these screenings and/or assessments are deemed necessary or advisable by the State of Florida and/or the ELCFG.  With this document, the ELCFG has my permission to release screening and/or assessment information and results to my child's SR and/or VPK provider, the Florida Diagnostic and Learning Resources System (Child Find/FDLRS), Early Steps and any other diagnostic agency as necessary.  I certify that I am legally responsible for this child.  I understand this information will remain confidential and will be used solely for the benefit of my child.  This consent is effective for one year from the date of assessment.

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.