Vision, Dental, & Scoliosis Screening Opt-Out Form
Dear Parents/Guardians

The General Laws of the State of Rhode Island 23-1-18 (4) section R 15-21 SCHO, Rules and Regulations for School Health Programs, require the following mandatory health screenings during the school year.

Vision Screening - Grade 7
Dental Screening - Grade 7
Scoliosis Screening - Grade 6 & 8

As the parent or guardian, you have the right to exclude your child from any or all of the health screenings.

IF YOU CHOOSE TO EXCLUDE YOUR CHILD, IT IS YOUR RESPONSIBILITY TO PROVIDE THE SCHOOL WITH SATISFACTORY EVIDENCE THAT THE SCREENINGS HAVE BEEN COMPLETED WITHIN THE PRECEDING SIX MONTHS.

If you wish to exclude your child from any or all of the mandatory health screenings, please complete the following and return the School Health Clinic on or before October 13, 2017.




Name of Child *
If you wish to exclude your child, please type their name in the space provided below and using the LastName, First Name method.
Your answer
Grade *
Please select the child's grade from the list below.
Please exclude my child from the following: *
Please select the screening that you wish to exclude your child from participating in.
Permission *
By clicking on the box below, I acknowledge that I have reviewed this document and agree to its terms. I understand that I am requesting that my student be excluded from this testing and will provide appropriate evidence that the screenings have been done by my healthcare provider(s).
Required
Parent
Please include your name in the space below.
Your answer
Date
Please select the date that you filled this out.
MM
/
DD
/
YYYY
Comments
Please provide any additional information in the space below.
Your answer
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