Center Name* Contact Person* Physical Address* Phone Number* E-mail Address In what month/year would you like to schedule your screening? If there particular days that would work best for a screening, list them. How many children attend your center? Center type (you can click multiple options) Private or church-based daycare center Home-based daycare center Head Start or Early Head Start State-funded Pre-K (ex., OSR) Pre-K housed within public elementary school Other
