Special Needs Screening Consent Or Waiver Form printable pdf download

Special Needs Screening Consent Or Waiver Form

SPECIAL NEEDS SCREENING CONSENT or WAIVER FORM

Please complete the appropriate section(s) below:

I, (print name)

_____________________________________________________________________________________,

agree or

decline to be administered the (print name of instrument)

_____________________________________

to determine the probability of a learning

disability

agree or

decline to be administered the (print name of instrument)

______________________________________

to determine the probability of ADD or

ADHD

agree or

decline to be administered a vision and/or hearing screening to provide information

about visual and/or auditory functions and processing

If I agree to screening (s), it (they) will take place on or about (date)_______ at (program

name)________________________.

Results of the screening will be reviewed by one or more staff members of the above named program and

will be utilized for the

purpose of instructional planning. Results of the screening (s) will be maintained in a secure location at the

above named program and will not be released to a third party without the consent of the student/parent or

guardian.

_____________________________________________________________________________________

Signature of Student/Parent or Guardian*

Date

_____________________________________________________________________________________

Signature of Program Representative

Date

*Students under the age of 18 must have this consent form signed by the student’s parent or

guardian.

Special Needs Screening Consent Or Waiver Form