Parent Permission Form For Health Screenings
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1Rick Scott
Rick Scott
Rick Scott
Rick Scott
Mission
Mission:
Mission
Mission
Governor
To protect, promote & improve the health
of all people in Florida through integrated
John H. Armstrong, MD, FACS
John H. Armstrong, MD, FACS
John H. Armstrong, MD, FACS
John H. Armstrong, MD, FACS
state, county & community efforts.
State Surgeon General & Secretary
Vision
Vision
Vision
Vision: To be the Healthiest State in the Nation
Parent Permission Form for Health Screenings
Student: ________________________
School: _____________________
Date of Birth: _________
Grade Level: _________
Teacher: ____________________
Dear Parent/Guardian,
Florida Statute 381.0056 mandates the Florida Department of Health in cooperation with the
Department of Education provide student health screenings for possible identification of unknown or
unrecognized diseases or defects. Screenings will take place in grade levels K, 1, 3, and 6. Parents
will be notified in writing of screening results by the Florida Department of Health in Brevard County.
Please indicate your choice for participation in the following screenings; if the school does not
receive a response your child will be screened.
YES
NO
Vision – school entry and grades K, 1, 3, and 6
Hearing – school entry and grades K, 1, and 6
Scoliosis (Curvature of the Spine) grade 6
Height & Weight (BMI) grades 1, 3, and 6
____________________________________
__________________
Parent / Guardian Signature
Date
If you have any questions please contact the DOH-Brevard School Health Program office at
(321)269-6311
Thank you
HD 306E (rev 07/13)
Florida Department of He
Florida Department of He
Florida Department of He
Florida Department of Health
alth
alth
alth
Brevard County
TWITTER:HealthyFLA
2575 N Courtenay Parkway • Merritt Island, FL 32953-4147
FACEBOOK:FLDepartmentofHealth
YOUTUBE: fldoh
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