Hearing & Vision Health Screening Request Form
Congratulations on selecting our innovative and dynamic screening experience for your scholars! The BASYC Youth Health & Wellness screening process offers opportunities for continued education, early detection and provide clear records of scholar performance. To help us customize your request for vision or hearing screening for preventive care needs, please fill out and submit the following information.
Person of Contact:
*
First Name
Last Name
Institution Name:
*
Address
Street Address
City
State / Province
Postal / Zip Code
Email:
*
Phone:
*
Program Type:
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Select Screening(s)
*
Please Select
Vision Screening
Hearing Screening
Grade(s) screening
*
Pre-K 3
Pre K-4
1st grade
2nd grade
3rd grade
4th gradew
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12 grade
Projected number of scholars to be screened
*
10-100
101-200
201-300
301-400
401-500
501-600
601-700
701-800
801-900
901-1000
1001-1200
Select a preferred screening date and time
*
-
Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Comments
Verification check
*
Sign signature
*
Print Form
Submit
Clear Form
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