Child Screening Registration Form

Happy Talkers Early Screenings
We want your child's screening experience to be as enjoyable and effective as possible! Please complete the following form to the best of your ability. Getting to understand your child and your concerns in advance will help our team best serve your needs.
If you have difficulty answering any sections, a Happy Talkers volunteer will help you at the Screening Event.
We look forward to meeting you and your child!
Child's Name*
First NameLast Name
Person filling out this questionnaire*
First NameLast Name
Relationship to child
Child's Birth Date*
MonthDayYear
Child's Gender*
MaleFemale
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
E-mail Address*
example@example.com
School/School District*
Child's Physician/Pediatrician*
If your child is not currently seeing a doctor, please enter "none."
Physician's Phone Number
Physician's E-Mail
If no current physician, please leave blank.
Date of Last Medical Exam
MonthDayYear
Translator Needed?*
How did you hear about us?*
Other- please explain:

Happy Talkers Early Screenings