Preschool Child Find Screening Form

Wayne County Public Schools Parental Consent for Child Find Screening

A notification has been made for your child,_______________________________________________, to Wayne County Public Schools for educational purposes.  We now need your permission to complete the screening.  Screening may include the following:

        1.   Hearing, vision, and health screening
        2.   Child observation
        3.   Parent/teacher conference
        4.   Developmental screening
        5.   Speech/language screening
        6.   Social Developmental/Childhood History Form

Please sign the consent form below.  If you wish to have your child screened at his/her daycare or preschool, please fill in the name of the center below.  You, along with the notification source, will be given or sent the results of the screening.  If a referral for evaluation is indicated, you will be contacted in order to obtain permission for evaluation.

Yes, I give permission for my child,_________________________________________________________, to be screened.

Signature: _________________________________________Date_______________________________

I prefer that my child be screened at his/her daycare or preschool.                         YES                    NO

Name of daycare or preschool: _________________________________________________________


No, I do not wish to have my child,_________________________________________________________, screened at this time.


Any questions please contact Rhonda Wiggins-Wayne County EC Preschool Program at 919-705-2709 or fax form to 919-580-3610
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