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Student Health Services OPT-OUT /
Exclusión voluntaria de atención de los servicios de Salud para Estudiantes
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Student First Name
Nombre del estudiante
*
Your answer
Student Last Name
Apellido del estudiante
*
Your answer
Student Date of Birth
Fecha de nacimiento del estudiante
*
MM
/
DD
/
YYYY
Student ID Number
Número de identificación del estudiante
Your answer
Current Student Grade
Grado actual del estudiante
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Choose
PreK
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
School
Escuela
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Choose
Archer Lodge Middle
Benson Elementary
Benson Middle
Choice Plus Academy
Clayton High
Clayton Middle
Cleveland Elementary
Cleveland High
Cleveland Middle
Cooper Academy
Corinth Holders High
Corinth-Holders Elementary
Dixon Road Elementary
East Clayton Elementary
Four Oaks Elementary
Four Oaks Middle
Glendale-Kenly Elementary
Innovation Academy at South Campus
Johnston County Career & Technical Leadership Academy
Johnston County Early College Academy
Johnston County Virtual Academy
McGee’s Crossroads Elementary
McGee’s Crossroads Middle
Meadow School
Micro Elementary
North Johnston High
North Johnston Middle
Pine Level Elementary
Polenta Elementary
Powhatan Elementary
Princeton Elementary
Princeton Middle/High
River Dell Elementary
Riverwood Elementary
Riverwood Middle
Selma Elementary
Selma Middle
Smithfield Middle
Smithfield-Selma High
South Johnston High
South Smithfield Elementary
Swift Creek Middle
Thanksgiving Elementary
West Clayton Elementary
West Johnston High
West Smithfield Elementary
West View Elementary
Wilson’s Mills Elementary
JCPS provides the following support for students. Checking an item below indicates you wish to Opt-Out of this service for your student.
I do not want my student to receive the following (check all that apply):
JCPS ofrece el siguiente apoyo a los estudiantes. Marcar una de las opciones a continuación indica que desea cancelar este servicio para su estudiante.
No quiero que mi estudiante reciba lo siguiente (marque todas las que correspondan):
*
Individual Hearing Screening Examen auditivo individual
Individual Vision Screening Examen de la vista individual
Individual Health Screening Examen de salud individual
Mass vision screening 1st grade Examen de vision masivo de 1 grado
Mass vision screening 5th grade Examen de vision masivo de 5 grado
Required
Your first name
Tu nombre
*
Your answer
Your last name
Tu apellido
*
Your answer
What is your relationship to this student?
¿Cuál es su relación con este estudiante?
*
Your answer
What is the best way to contact you?
¿Cuál es la mejor manera de contactarlo?
*
Your answer
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