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.
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