Child's Name:
Child's Birth Weight:
for my child to receive Developmental, Speech / Language, Hearing, Vision, and Social / Emotional screening during the first 45 days of the school year. The screening is to determine if further evaluation is necessary.
for my child to be tested for lead, and agree to complete the e-consent for the County Health Department to administer a blood lead test, if necessary. The parent will be notified of screening results. Lead results / tests may also be obtained through my primary care physician.