SCAN Border Project LAUNCH
May 13th TAMIU Screening Developmental Event
Parent's Name
*
First Name
Middle Name
Last Name
Parent's Email
*
example@example.com
Parent's Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Name
*
First Name
Middle Name
Last Name
Child's Birthdate
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Was child born prematurely?
*
Yes
No
By how many weeks?
*
Select appointment time for child's developmental screening:
*
2:00-2:30 p.m.
2:30-3:00 p.m.
3:00-3:30 p.m.
3:30-4:00 p.m.
Submit
Should be Empty:
