Please download these forms, complete and either print and bring to screening or email them to address below.  Along with the forms below, please bring a copy of your child's birth certificate and immunization records to their screening appointment.

Forms to be completed for Screenings: 

    1. Hearing and Vision Worksheet

    2. Screening Registration Form

    3. Child Health and Developmental History (3-5 years)

    4. Early Childhood Screening Consent

    5. Early Childhood Screening Release of Information

     Please choose the ASQ form below appropriate for your child's age on their screening day:
     ASQ:SE-2 for 2 yrs, 9 mo-3 yrs, 5 mo

     ASQ:SE-2 for 3 yrs, 6 mo-4 yrs, 5 mo

     ASQ:SE-2 for 4 yrs, 6 mos- 7 yrs

     7. Complete Online enrollment.  
        

Paper forms can be printed and brought to the appointment or emailed to lisa.simenson@myprowler.org