PreSchool Screening Sign Up Form

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	New Hartford Public Schools PRESCHOOL Program If you are interested in having your child screened for the Preschool Program, please complete the following form below and submit. If you have any questions or would like more information about our preschool program, please call the Special Education Department at (860)379-1653

	Child's Name*

	Date of Birth*
	mm/dd/yyyy

	Do you have any concerns about your child's development?*
	Do you have any concerns about your child's development?* Yes No

	Parent(s) Name*

	Address* Street, City, State, Zip

	Phone*

	Email