Health Screening Parental Authorization Form
Please fill out this form to authorize health screening for your child.
Parent/Guardian Full Name
*
First Name
Last Name
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorization Consent
*
Parent/Guardian Signature
*
Submit
Should be Empty: