Metro United Way - Give. Advocate. Volunteer

Are you a resident of Kentucky or the counties of Floyd, Clark or Harrison in Southern Indiana?*

Yes
No

Unfortunately, due to copyright agreements, Metro United Way is limited to distributing this tool to residents of our service area in Kentucky and Southern Indiana. We are sorry, but requests completed by residents of other states will not be processed.

If you live outside the Kentuckiana area and you have concerns about your child’s development, try contacting your local school district or your state’s early intervention program.

Are you the parent or legal guardian of the child you are requesting an ASQ for?*

Yes
No

Due to privacy restrictions, a legal guardian must provide permission to complete an ASQ on their child. Please click here to download a permission form which the parent can sign to allow you to complete an ASQ.

Email your completed form to Kimberly Broecker at kimberly.broecker@metrounitedway.org.

In what county do you live?*

The Oldham County Health Department serves as the Developmental Screening Hub for Oldham County. Please visit their WEBSITE HERE to enroll in their screening hub.

Child's Name

First Last

Child's date of birth

*Note: the child must be under 5 years, 6 months old to qualify.

Please tell us how you identify your Child's gender*

Was your child 3 or more weeks premature?*

Yes
No

How many weeks premature?*

Please enter a number greater than or equal to 3.

Child's Ethnicity*

Please tell us how you identify your child's race:*

Preferred language?*

English
Spanish

Are you involved with or enrolled in Play Cousins Collective?*

Yes
No

Play Cousins Collective offers a wide variety of opportunities for parents including parent café’s, cultural events, field trips, and parent support groups. Would you like to learn more about how to become more involved in Play Cousins Collective?*

Yes
No

By clicking yes, you are giving permission for Metro United Way to share your contact information and basic ASQ participation with Play Cousins Collective. Someone from Play Cousins Collective will be in touch with you to provide additional information.

How did you hear about this opportunity?*

Relationship to the Child*

Your Name*

First Last

Address*

Street Address City State ZIP Code

*NOTE: Due to licensing agreements, the ASQ is only available to residents of Kentucky and Southern Indiana. Requests completed by residents of other states will not be processed. If you live outside the Kentuckiana area and you have concerns about your child's development, try contacting your local school district or your state's early intervention program.

Email Address:

Phone*

By submitting this form, I attest that I am the above’s legal guardian and I agree to enroll my child in the Ages & Stages Questionnaires monitoring program and into My Big Little Adventure’s weekly newsletter. For more information on My Big Little Adventure, please click here.

By providing my child's health care provider information, I agree to allow Metro United Way (MUW) to share information about my child and my child's ASQ results with my health care provider. You may opt out at any time by contacting kimberly.broecker@metrounitedway.org

To better communicate and facilitate your participation in the program, If you are involved or enrolled with Play Cousins Collective, or their advocates, Metro United Way will be providing Play Cousins Collective with limited access to of your family/child’s information.

Play Cousins will have access to:

General contact information.
Interactions between the developmental screening coordinators and your family.
Your participation rates and if you are due for a gift card.
Any needed services, and any information regarding referrals made by Metro United Way and/or connections made by the family

For additional information, please click here.

You may opt out at any time by contacting kimberly.broecker@metrounitedway.org.

Sign up below to receive your first Ages & Stages Questionnaire!

It’s quick, easy, and free to gain access to these tools. Here’s how:

Sign Up:

The Oldham County Health Department serves as the Developmental Screening Hub for Oldham County. Please visit their WEBSITE HERE to enroll in their screening hub.

Already enrolled?

Have questions?

Sign up below to receive your first Ages & Stages Questionnaire!

It’s quick, easy, and free to gain access to these tools. Here’s how:

Sign Up:

The Oldham County Health Department serves as the Developmental Screening Hub for Oldham County. Please visit their WEBSITE HERE to enroll in their screening hub.

Already enrolled?

Have questions?

Subscribe