South Carolina Association of Community Action Partnerships
Early Head Start Child Care Partnerships
Screening Consent Form
Child's Last Name:
*
Child's First Name:
*
Child's Middle Name:
Parent's Last Name:
*
Parent's First Name:
*
Parent's Middle Name:
Center:
*
Betty's Daycare
House of Joy
House of Smiles
Kiddie University
Little Smurf's
Midlands Primary
Newberry CDC
Pawley's Island
Progressive Family Life CDC
Small Minds of Tomorrow II
Thornwell
Wright Way CDC
Wright's DayCare
I give permission for my child
to receive all health screenings listed below. This information will be used to meet requirements for participation in our program and to provide additional medical follow-up or special services that my child may need while in SCACAP Early Head Start Childcare Partnership program. I understand that I will be notified of all screening results and follow-up, if required.
Growth Assessment (Ht and Wt)
Dental Screening
Hearing Screening
Vision Screening
Social Emotional Screening (ASQ-SE)
Developmental Screening (ASQ-3)
Mental/Behavioral Health Observations
**This screening does not replace on-going care from your child’s health care provider or dentist.**
I confirm that I have read and understand this form.
*
By checking this option, I choose to manually sign this form.
Clear Signature
Signature required
Please check any one sign.
By checking this option, I prefer to have the system electronically sign this form for me.
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Parent Signature
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