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Health Screening Consent Form

Dear Parent or Guardian,

In an effort to better address the health needs of students, the State of Tennessee requires that throughout the 2008-2009 school year, the Hamblen County school system must screen all students in the K, 2, 4, 6, 8, and 9th grades. Trained school nurses and health care personnel will complete all screenings with strict adherence to confidentiality of each child and adolescent screened. Please note there will be no charge for these services. The screenings will include:

  • Height

  • Weight

  • Blood Pressure

  • Vision

  • Hearing

    IF YOU DO NOT WANT YOUR CHILD TO PARTICIPATE IN ANY OF THE SCREENINGS, PLEASE COMPLETE AND SIGN THE FORM BELOW AND RETURN TO YOUR CHILD’S HOMEROOM TEACHER.If you have any questions or concerns, please feel free to contact me at the number listed below.  Thank you. 
Kellie C. Smith, M.P. H.
School Health Coordinator




I DO NOT want my child to participate in the following screenings (please check all that apply):

___Height ___Weight ___Blood Pressure ___Vision ___Hearing


Child’s Name: ____________________________________________________

Parent or Guardian’s signature: _______________________________________

Date: ___________________________________________________________