School Screening Opt In/Out Form

Parent/Guardian Details

Parent / Guardian's First Name

Parent/Guardian's Last Name

Parent Email

e.g. abc@xyz.com

Parent Phone Number

e.g. 000-000-0000

Child Details

Child's First Name

Child's Last Name

Child's Date of Birth (mm/dd/yyyy)

School Information

School (Jurisdiction or County Location)

School

Grade

I confirm I have read and understood the information provided and the importance of screenings provided by Public Health.

Choose from drop downs to opt in/out school screening

Dental Opt In/Out

NOTE: Your child's school is not offered vision screening this year. Please refer to optometrist in our local area from the school health page

Vision Opt In/Out

I have read, understand and agree to the Grand Erie Public Health's Privacy Statement regarding the collection of information.