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

*I have read the provided information about the MtFFC screenings.

*I wish to have my child participate in the screening and monitoring program. 

*I have received a copy of the HIPAA statement:  ESEP HIPAA

*I agree to be contacted by an Easterseals specialist, who will share the results with me and also give me activities and/or connect you to community resources in line with my child’s individual needs.

*My child’s information will only be shared with other agencies (referral for full evaluation, doctor’s, caretakers, childcare centers, community organization, etc…) with my consent, which I completed here:  ESEP Consent

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