TCS Vision Screening Opt-In Form Survey

Dear Parent or Guardian,

Healthy children perform better in school. As part of an ongoing initiative throughout the state of North Carolina, several free health screenings will be offered to Transylvania County students during the school year.

Vision Screenings: School personnel trained and certified by the Prevent Blindness Association will do a vision screening on each student in Pre-K, 1st through 5th grade, 7th grade, and 10th grade. A Transylvania Public Health nurse will re-screen the students who do not pass the initial screening. For students with 20/40 acuity in one or both eyes, parents will be notified of the results and will be asked to seek an evaluation with a doctor. The nurse will follow up with the parents of those students.

If you would like your child to participate in these screenings, please select the option below and type your electronic signature.

If you do not authorize the screening, or if this form is not completed, your student will not be screened.

Thank you for your cooperation.

HEALTH SCREENING AUTHORIZATION(Required.)

I give permission for my student to participate in the VISION SCREENINGS administered during the 2026-2027 school year.

I DO NOT give permission for vision screening.

INFORMATION ABOUT YOUR CHILD(Required.)

Child’s Legal Name:

School:

Grade:

Typing your name below serves as your signature authorizing your child to receive the health screenings marked above.

AUTHORIZING SIGNATURE (parent/guardian for students under age 18)(Required.)

Parent/Guardian Name:

Date: