Edina Community Education Services

Early Childhood Developmental Screening - Appointment Form

Early Childhood Developmental Screening
5701 Normandale Road
Edina, MN 55424
suskemper@edina.k12.mn.us
 952-848-4299
952-848-4239 (fax)

To schedule a screening appointment for your child, please complete this form
and submit electronically or print and mail/fax to the address above

An e-mail message confirming your appointment will be sent to you within two school days.

Child First:  MI:  Last:
Child Date of Birth: Month  Day  Year
Gender:   Female    Male
Parent First:  Last:
Home Address:
City:  State:  Zip:
Email Address:
Daytime Phone:  ###-###-####
Alternate Phone:  ###-###-####
Preferred Appointment Date:
Preferred Appointment Time:
Alternate Date:
Alternate Time:
Which language is most often spoken in your home? 
       If Other, what language? 
Should we provide an interpreter for you and/or your child? 
    Yes    No
Any additional information about your request (optional)
  

Screening is by appointment only.  
Appointments are scheduled every 30 minutes on the half hour.
At this time we are scheduling for the following dates:

Friday, August 24 12:30 PM – 3:00 PM
Friday, September 7 8:00 AM – 3:00 PM
Saturday, September 8 8:00 AM – 11:30 AM
Thursday, September 20 1:00 PM – 6:30 PM
Friday, September 21 8:00 AM – 3:00 PM
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