School/Daycare Screenings Enrollment Form

School/Daycare Screenings Enrollment Form

Please fill the form below to sign up for our School/Daycare screenings services.
Your Name:*
Email*
example@example.com
Are you reaching out on behalf of a school, daycare center or summer camp?*

Daycare (including PreK-K)School (Grades Pre-K-12)Summer Camp
Organization's Name*
Phone Number*

Area CodePhone Number
Organization's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Principal/Decision Maker Name*

First NameLast Name
Principal/ Decision Maker Email*
example@example.com
When is your first day of school/ daycare/ summer camp?*

MonthDayYear
How many students/staff members need to be registered to receive services? *
Which month(s) are you available to have your screenings completed this upcoming school year?*

JuneJulyAugustSeptemberOctoberNovemberDecemberJanuaryFebruaryMarchAprilMay
Approved dates for student comprehensive speech and hearing screenings*

MonthDayYear
Date
Do you have any partnering schools or organizations who may be interested in our services? If so please list them below.
Do you believe the teachers/staff of the school would be interested in back to school supplies?

YesNoI am not sure
Are you interested in adding our vision services?*

YesNoI am not sure
Would you like us to provide your site with consent forms and flyers to advertise our services to parents?*

YesNoI am not sure
What is something you will need for the upcoming school year that may not be easily accessible for your organization?
How can High Level Speech and Hearing Center assist with keeping your environment safe and healthy?
What challenges do you foresee when performing speech and hearing screens this year?
Questions/Comments:
Should be Empty: