Daycare ScreenersPlease complete this permission form in order for your child to be screened if you did not return a paper copy. Child's Name * First Name Last Name Child's Date of Birth * Caregiver's Name * First Name Last Name Email * Phone * (###) ### #### What are your concerns about your child’s speech and/or language skills? * Has your child previously received speech therapy or early intervention services? * Yes No If yes, please describe the services and the dates received: Please state what times he/she is at school: * I give permission for, CHILD LISTED ABOVE, to participate in a speech and/or language screening at his/her school and for the results to be shared with the school. Yes Date * MM DD YYYY Thank you!
