Fillable Permission to Screen Childs First Name Childs Last

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Permission to Screen Childs First Name Childs Last

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The Permission to Screen Childs First Name Childs Last form is 1 page long and contains:

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Regional Office of Education #08
27 S. State Ave., Suite 101, Freeport, IL 61032
Phone: 815.599.1408 Fax: 815.297.9032
www.roe8.com
Permission to Screen
Child’s First Name Child’s Last Name
I, the parent or guardian of the above-named child, give my permission for this child to participate in a
developmental screening.
Signature of parent or guardian Date
I, the parent or guardian of the above-named child, give consent to the screening agency to release
information to the local early childhood programs for referral purposes and to the Local County Health
Department for data collection only.
Signature of parent or guardian Date
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Permission to Screen Childs First Name Childs Last

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Completed 25 May 2021

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