Beaufort Jasper EOC Head Start

Permission to Screen Assess

Child's Last Name:*

Child's Middle Name:

Child's First Name:*

Date of Birth:*

What program option are you registering for?*

Center:*

Children enrolled in the Head Start program are required to receive the following screenings within the first forty-five (45) days of enrollment.
Head Start programs are also required to provide a developmental assessment to all children at least three (3) times during the school term.
We are requesting your permission to screen and assess your child using the following screening and assessment tools:

Developmental Indicators for the Assessment of Learning Fourth Edition (DIAL-4)
Hearing and Vision Screenings
BRIGANCE Early Head Start Screen lll
Teaching Strategies Gold (TSG) Developmental Assessment
Mental Health Classroom Observations

I give my permission for my child to receive the above screenings and assessments while enrolled in the Head Start Program.

Parent(s) First Name:*

Parent(s) Middle Name:

Parent(s) Last Name:*

I confirm that I have read and understand this form. *

By checking this option, I choose to manually sign this form.

By checking this option, I prefer to have the system electronically sign this form for me.

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Parent Signature

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