Consent for PUF/MM/ELL Eligibility and Screening/Assessment

Fueling Brains Academy – ECS Kindergarten Registration
At FB Education Services, our screening process helps identify areas of concern based on parent/guardian observations. Screenings may assess language, motor skills, and social-emotional development and can include additional observations of the child within their learning environment. The results are straightforward and will indicate either a pass or the need for further assessment.

This JotForm serves as your consent for both the initial screening and, if indicated, any additional comprehensive assessments, which may cover areas such as speech or language, fine or gross motor skills, and social-emotional development. You will be contacted based on the results of the assessment, regardless of the outcome. If your child passes the screeners and no further assessment is needed, we will also reach out to inform you.
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Screening and Assessment Consent

By continuing, you are giving consent for your child to be screened and assessed by a member of our team, as needed.
Please note, this entire process is provided at no cost to parents and is funded by Alberta Education’s Program Unit Funding (PUF), Mild Moderate (M/M), or English as an Additional Language (EAL) funding.

To be eligible for funding through Alberta Education’s PUF, M/M, or EAL programs, the child must be at least 2 years and 8 months old (2.8 years old) on or before August 31, 2025. If the child does not meet this age requirement, they may not qualify for these funding programs at this time.

If you have any questions about age requirements or eligibility, please email edservices@fuelingbrains.com, and a team member will get back to you.
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Signature for Consent to Screen and Assess*
Parent / Legal Guardian Name *

First NameLast Name
Child's Legal Name*

Legal First NameLegal Middle NameLegal Last Name
** Please ensure that the child's name is written exactly as it appears on their birth certificate or passport.
Child's Preferred Name
If different from their Legal Name.

To be eligible for funding through Alberta Education’s Program Unit Funding (PUF), Mild/Moderate (M/M), or English as an Additional Language (EAL) programs, the child must be at least 2 years and 8 months old (2.8 years) by August 31, 2025. If the child does not meet this age requirement, they may not qualify for these funding programs.
Child's Birthdate*

YearMonthDay
Child's birthday must be on or before December 31st, 2022 to be eligible.
You have entered a birthdate that indicates your child is under 2 years and 8 months of age.

Unfortunately, this means they are not eligible to receive PUF, M/M, or EAL funding through Alberta Education for the 2025/2026 school year. Therefore, we are unable to proceed with this submission at this time.

If you have any concerns about your child’s development, we recommend speaking with their pediatrician or family doctor. You may also reach out to your campus’ centre director for further assistance and support at the campus.

If you have any questions, please reach out to us at edservices@fuelingbrains.com.

Thank you.

Child's History with Previous Programs and Services
Please Note: If your child is currently attending an accredited Early Childhood Services (ECS) operator or a funded private school and/or receiving Program Unit Funding (PUF) or Mild/Moderate (MM) funding, or are attending a Kindergarten Program (outside of Fueling Brains Academy) for the 2025/2026 school year from another provider, they are not eligible to receive additional funding through FB Education Services.

If you are unsure and would like to speak to a member of our Education Services team, please email edservices@fuelingbrains.com or visit https://www.fuelingbrains.ca/education-services/ for more information.
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YesNoUnsure
You have indicated “yes” on the JotForm, confirming that your child is currently enrolled in another program receiving funding through PUF, MM, or Kindergarten. As a result, they are not eligible for additional funding through FB Education Services at this time and are unable to proceed with the form.

Should you have any questions or concerns regarding your child’s eligibility, please don’t hesitate to contact us at edservices@fuelingbrains.com or via telephone at 587-392-9045. Thank you for your understanding.

Languages Spoken and Language Development
Languages spoken at home and percentage of time spoken:*
(E.g., English 70%, Spanish 30%)
If more than one language, what do you consider your child's primary language? *
(E.g., Spanish)
YesNoUnsure
You have indicated "Yes" to the question above, please provide additional information about your concerns
Concerns may include child's ability to understand and communicate, as well as their speech sounds and pronunciation of words in any language spoken
How old was your child when they had their first words (e.g., 12 months, 14 months, etc.) in ALL languages spoken at home? *
Examples of first words are "mama"; "dada"; "up"; etc. or approximations - "ma"; "da"; "baba" for 'bottle'
What age did your child combine two words ("mama go"; "more ball"; "dada up", etc.) in ALL language spoken? *
Example: "dada up", 24 months; 2 years

Medical and Developmental History
What age did your child take their first steps? *
Example: 13 months; 1 year 1 month
Was your child born prematurely? Any complications? Please provide details*
Anything to note? Normal? C-section? Late?
Does your child have any known medical conditions or allergies? If yes, please provide details:
Has your child received any previous diagnoses or evaluations related to their development? If yes, please provide details:
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What were the results from the hearing test? Anything notable? Please provide details below:
*Please be aware: It is advisable for all children to undergo a hearing and vision screening before starting Kindergarten, typically around the age of five.
Is there any additional information or specific questions you would like to share with us?

By signing and submitting this questionnaire, you confirm that the information provided is accurate to the best of your knowledge. This information will be treated with confidentiality and used solely for the purpose of assessing and providing appropriate early intervention services for your child.
Date*

MonthDayYear
Date
Signature*
Should be Empty:

Fueling Brains Academy – ECS Kindergarten Registration