Weeks Premature
(put "0" if not premature)

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For ASQ:SE-2™ English

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Authorization for Participation and Sharing of Personal Information

By submitting answers to this questionnaire, I understand and acknowledge that:

My participation or the participation of my child in the Help Me Grow Inland Empire program is voluntary.

The information I am voluntarily providing on these questionnaires to Help Me Grow Inland Empire will be used internally and also shared with third party entities such as, but not limited to, my child’s early childhood educator and my child’s medical or behavioral health provider in order to assess my child for developmental delay and to link my family to community resources.

I have the right to discontinue participation on this program or limit the disclosure of my information at any time by submitting my request in writing to Help Me Grow Inland Empire, Compliance Manager, 11234 Anderson Street, Suite CH1816, Loma Linda, CA 92354. I understand that the revocation will not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization will remain valid.

I have read the above statements and I am at this time authorizing Help Me Grow Inland Empire  to use and disclose the information provided on this questionnaire as Help Me Grow Inland Empire, its affiliates, subcontractors, and its representatives deem appropriate in order to provide my child and my family with developmental screening tools and community resources.

Note: By clicking "Submit", you are agreeing to both our Family Access End User License Agreement and any other consent or authorization information outlined on this page.