Pretend City Children's Museum

29 Hubble 
Irvine, CA 92618
949.428.3900
www.pretendcity.org

Thank you for taking an important step in better understanding your child’s growth and development! Children grow up so fast – they are crawling, walking and talking before you know it. That’s why Pretend City Children’s Museum, through its child development initiative Good To Go From Head To Toe, is working together to help you and your child’s doctor follow your child’s development. The questionnaire may be completed every 2, 4 or 6 month period. You will be asked to answer questions about some things your child can and cannot do. The questionnaire includes questions about your child's communication, gross motor, fine motor, problem solving, and personal social skills. By providing you with access to this free online developmental checkup, you can track your child’s development every step of the way!

Please enter your child's birth date and the number of weeks he or she was born premature below to start the screening. Please note that the information you enter into this website is secure and cannot be seen or accessed by anyone other than the program employees who have invited you to participate in this screening.

We look forward to your participation in ASQ-3!

 

The information you enter into ASQ Online is confidential and can only be accessed by Pretend City staff. However, information entered into the OC Children's Screening Registry can be accessed by Help Me Grow and authorized OC Children's Screening Registry users.  Please note that you can opt out of sharing your child’s information in the OC Children’s Screening Registry when completing the Child Information Section during this registration process or at any time in the future by contacting Pretend City Children’s Museum, without any consequences to receiving services. You acknowledge that your opting out cannot and will not recall information that has previously been released in reliance upon your consent provided herein.



(put "0" if not premature)


By completing this questionnaire, you are giving your consent to allow our staff to review the ASQ-3, send the results to your e-mail, and share an electronic copy of the results with the Help Me Grow, and the OC Developmental Screening Registry. As our gift, you will also receive a free admission ticket to Pretend City Children's Museum so you can continue playing and learning with your child. If we have any questions about your child's ASQ-3, we will contact you by phone at the number you provided.

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.

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