Permission School Screening Form

WALLKILL VALLEY REGIONAL HIGH SCHOOL

HEALTH OFFICE

MEDICAL PERMISSION/DENIAL FOR SCHOOL HEALTH SERVIVES

Must be completed and returned to the School Health Office by September 20___

Child's Name:____________________________________Fall 20___ Grade:__________

Listed below are the services that are part of the School Health Program and performed by the Registered Nurse in the Health Office. Please put a mark ( X ) to indicate acceptance or denial of these services.

9^th Grade 10^th Grade 11^th Grade 12^th Grade

Height Height Height Height

Weight Weight Weight Weight

Blood Pressure Blood Pressure Blood Pressure Blood Pressure

Scoliosis Vision Scoliosis

Hearing

_____YES, please perform the appropriate screenings on my child for their grade.

_____I do NOT wish my child to receive any of the above services for this school year and I will have my child examined by their private medical doctor and provide the school with a copy.

_____I have submitted a completed ATHLETIC PARTICIPATION PHYSICAL form, pursuant to NJAC GA:16-2.2.

Date: ____________________ Parent/Guardian Signature ________________________

Back