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School Health Assessment Notification Form
Please read the entire form and then answer the following questions. One form per child.
https://www.parker.k12.sd.us/cms/lib/SD01916961/Centricity/Domain/175/2020_Health_Assessment_HIPPA_Form.pdf
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* Indicates required question
Parent Name
*
Your answer
Child Last Name
*
Your answer
Child First Name
*
Your answer
Child's grade in 2020-21 school year
*
Choose
K
1
2
3
4
5
6
7
8
9
10
11
12
Check one of the following: (refer to the pdf above for information.)
*
I agree to my child participating in the health screenings listed in the document.
I agree to have my child participate but do NOT want an abnormal hearing or vision screening result to be shared with school personnel.
I decline to have my child participate in school health screening
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This form was created inside of State of South Dakota K-12 Data Center.
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