Language
English (US)
Spanish (Latin America)
Screening Clinic Contact Form
If you prefer to contact our office directly please call 620-225-5177 Se Habla Español
Arrowhead West Infant Toddler Services Serves Children ages 0 to 3 years. If your child is ages 3-5 years of age please contact the SKACD #613 at 620-371-1061 to have your child screened.
Child's First Name
*
Child's Middle Initial
Child's Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender:
*
Male
Female
Race (Select all that apply)
Alaska Native/American Indian
Asian
Black
Native Hawaiian/Pacific Islander
White
Ethnicity
Hispanic
Non-Hispanic
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
*
First Name
Last Name
Relationship to Child
*
Aunt
Father
Foster Father
Foster Mother
Friend
Grandfather
Grandmother
Legal Guardian
Mother
Sibling
Step Father
Step Mother
Uncle
Other
Parent/Guardian Phone
*
-
Area Code
Phone Number
Email
example@example.com
Primary Language Spoken in the Home
*
Interpreter Needed
*
Yes
No
What screening clinic location would you like to attend?
Please Select
Dodge City
Meade
Jetmore
Cimarron
Ness City
Kinsley
Ashland
Montezuma
Other
How did you hear about our screening?
Family/Friends
Medical/Health Dept.
NICU
Education Agency (EHS/PAT)
Daycare/DCF/Foster Care
Social Media (Facebook, newspaper, flyer in community)
Thank you for your information. Someone will be contacting you soon to set up an appointment.
Submit
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