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Edgewood Health Screening Opt out Form
If you do not want your child included in the vision and dental screenings, please complete the form below.
**Opt-Out responses must be received by Friday December 5th, 2025**
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* Indicates required question
Student first and last name
*
Your answer
Student Teacher Name
*
Your answer
Parent/Guardian name
*
Your answer
Parent/Guardian email address
Your answer
I would like to opt my student out of
*
Vision
Dental
Vision and Dental
Reason for Opting out
*
My student already receives regular dental/vision care
I want my student opted out of the screenings for religious beliefs
If you are opting out because your student already receives regular dental and vision care, please provide the names of your child's dental and vision providers below:
Your answer
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