Center for Community ILP
700 Katlian St
Suite B
Sitka, Alaska 99835

(put "0" if not premature)

For ASQ-3™ English

For ASQ:SE-2™ English

 I give consent for the Early Learning Program to screen my child named above.  I understand that if my child shows a questionable screening r4esult, that I may be offered a child developmental evaluation.

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