Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

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.

The information provided in this document is true, correct and complete. I have identified all parents and legal guardians for this child. The individuals identified in the “parent/legal guardian” section have the right to view child information and make educational decisions for this child, unless otherwise indicated here and supported with legal documentation. Further, I recognize that it is my responsibility to notify ABC Head Start Society should the above information change.

In accordance with the Freedom of Information and Protection of Privacy Act (FOIP), I accept ABC Head Start Society is authorized and required under the provisions of the School Act and its regulations to collect, use and disclose personal information that is necessary to provide educational programming and ensure a safe and secure environment for children.

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.