Giving Tuesday is Today - November 30th!

This Giving Tuesday, there are FIVE WAYS that you can help fuel the lives and dreams of friends, family and neighbors in our seven-county region. From fighting homelessness and food insecurity to offering kids their very own beds to ensuring our city’s youth have safe spaces – YOU can make a huge impact in our community!

Donate Today!

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 for Ages & Stages Questionnaires® by filling out the form below.
Receive a link to complete the questionnaire in your email
Play some games with your child and answer some questions
Metro United Way will call you if we have questions about your responses
Receive a letter with the results, a FREE BOOK, helpful tips, fun activities and connections to resources.
When it’s time, we’ll send you the next Questionnaire. We’ll keep sending them every few months until your child is 5 1/2.

Already enrolled?

Complete ASQ online. Click ASQ-3 or ASQ-SE to begin.

Have questions?

Contact Kimberly Broecker at 502-292-6159 or kimberly.broecker@metrounitedway.org

Sign Up:

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
Month
Day
Year

*Note: the child must be under 5 years, 6 months old to qualify.
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
How did you hear about this opportunity?*
Please tell us how you identify your Child's gender*
Relationship to the Child*
ARE YOU INVOLVED WITH PLAY COUSINS COLLECTIVE?*
- Yes
- No
If yes, who is your Advocate?*
Have you lived in Beecher Terrance anytime between June 2016 to present?*
- Yes
- No
IF YES – to help facilitate your participation in the Ages & Stages Developmental Screening Hub and to help your child receive any needed services, Metro United Way would like to share your contact information and your child's ASQ® results with Urban Strategies.
Do you consent to share your contact information and results with Urban Strategies?*
- YES - I give permission for Metro United Way to provide my contact information and results to Urban Strategies
- NO - I DO NOT give permission for Metro United Way to provide my contact information and results to Urban Strategies
CLICK HERE FOR A COPY OF THE CONSENT FORM.
Health Care Provider Name
(Example: Dr. Smith)
Health Care Provider Practice Name
(Example: ABC Pediatrics)
Your Name*
First Last
Phone*
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:
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.

Working every day to lift our community by mobilizing people and maximizing our community's resources to advance opportunity and equity for all.

Metro United Way is a 501(c)3 U.S. nonprofit organization.