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CA Healthy Kids Survey (CHKS) Withdrawal Form for DIS 7th and 8th grades and DHS 9th-12th grades. (You will need to complete this form for each student you wish to opt out. )
Only fill out this form if you
DO NOT
want your child to participate in the CHKS.
If you consent to having your child participate in the CA Healthy Kids Survey, there is no need to fill out this form.
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Email
*
Your email
By completing this form,
I DO NOT GIVE PERMISSION
, for my child to be in the California Healthy Kids Survey.
My CHILD's
first name
is:
*
Your answer
My CHILD's
last name
is:
*
Your answer
Student's grade level:
*
7
8
9
10
11
12
PARENT/GUARDIAN's first and last name
*
Your answer
By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.
*
Your answer
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