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

For ASQ:SE-2™ English

By submitting this form, I attest that I am the above’s legal guardian and I agree to enroll my child in the Ages & Stages Questionnaires monitoring program and into My Big Little Adventure’s weekly newsletter. For more information on My Big Little Adventure..

By providing my child's health care provider information, I agree to allow Metro United Way (MUW) to share information about my child and my child's ASQ results with my health care provider. You may opt out at any time by contacting kimberly.broecker@metrounitedway.org

To better communicate and facilitate your participation in the program, If you are involved or enrolled with Play Cousins Collective, or their advocates, Metro United Way will be providing Play Cousins Collective with limited access to of your family/child’s information.

Play Cousins will have access to:

• General contact information.
• Interactions between the developmental screening coordinators and your family.
• Your participation rates and if you are due for a gift card.
• Any needed services, and any information regarding referrals made by Metro United Way and/or connections made by the family.

You may opt out at any time by contacting kimberly.broecker@metrounitedway.org.

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.