FDLRS/Gateway Child Find 5683 US Hwy 129 South, Suite 1 Jasper, FL 32052 386.792.2877 800.227.0059 Permission for Preschool Screening

Child’s Name

DOB

Parent/Guardian:

Address:

I hereby grant permission for my child,

to be

screened by FDLRS personnel. I understand this is a screening and the results may indicate the need for further evaluation.

Yes, I am the legal guardian of this child or have provided proof of guardianship.

Signature of Parent/Guardian

White – FDLRS/Gateway

Date

Yellow – District

Pink - Parent