Boyne PS Hearing and Vision Screening Clinic Permission Form

Hearing and Vision Screening Clinic Permission Form
A fee of $25.00, which includes the processing and administration fee, is collected to help offset the cost of bringing the clinic to schools.

Please complete the permission form and online payment, as the link will close two business days prior to the clinic date.

This form must be completed for each child participating in the clinic.

If you choose to only screen your child's hearing the fee remains the same.

PLEASE NOTE: After submitting this form, you will be directed to a payment link. Your child's permission form will not be submitted or processed until payment is completed.
Child's Name*

First NameLast Name
Age*
Gender (Information required for colour vision test)*

MaleFemaleNon-binaryPrefer not to disclose
Does your child wear glasses?*
Grade*
Classroom Teacher*
School Name*
School Board *
Parent/Legal Guardian Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email (must be the same used for payment for refund purposes)*
Refunds can take 7-10 business days to process.
By submitting this form, I give my consent for School Screening Association to conduct hearing and vision screening for my child. I also authorize School Screening Association to share the screening results with my child’s principal to help support their learning and development.

Please note: Sharing results with the principal is essential to the success of this program. If you do not wish to have the results shared, please do not register your child, as participation requires this consent.

A copy of the screening results, complete with any necessary recommendations will be given to each parent/guardian.

If your child wears glasses, we will ONLY screen hearing and the fee remains the same.

Do not participate if your child has had Ear or Eye Surgery.

If your child has had a Tympanostomy (Ear Tubes) please call our office at 416-495-9485 prior to participation.

The screening program consists of:

Hearing and Middle Ear Function using an Audiometer & Tympanometer.

Near & Far Vision and Eye Muscle Balance. Colour Vision for boys (only) 6 years and up.

Screening results are not intended to replace a regular visit to the Audiologist or Optometrist.

PLEASE NOTE: After submitting this form, you will be directed to a payment link. Your child's permission form will not be submitted or processed until payment is completed.
Date permission given*

MonthDayYear
admin@look.ca

www.schoolscreeningassociation.ca
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Hearing and Vision Screening Clinic Permission Form

A fee of $25.00, which includes the processing and administration fee, is collected to help offset the cost of bringing the clinic to schools.

If you choose to only screen your child's hearing the fee remains the same.

admin@look.ca