I hereby give my consent for the child listed below to receive a medical and/or dental examination. / understand that these services are deemed necessary or advisable by Beaufort-Jasper EOC Head Start program and they will be conducted by a trained Head Start Staff or medical and dental provider contracted through Beaufort-Jasper EOC Head Start. / understand that / will be notified of my child's test results, if additional treatment is needed.

Medical Examination (includes but not limited to: height, weight, blood pressure, hematocrit, lead, hearing, vision and additional screening if necessary)

Dental Examination (includes prophy and fluoride treatment)