Date: ___________________

Dear Parent/Guardian:

In accordance with the School Health Law a scoliosis screening test shall be administered to all students in grades 6 and 7 and to all age-appropriate students in ungraded classes.

Scoliosis is a sideways curvature of the spine most commonly found during the adolescent growth period. Early recognition of scoliosis followed by close observation and treatment may prevent serious deformities.

Screenings are conducted in conjunction with physical education classes. If a deviation is found , a second screening will be conducted at a later date. As stated in school health law, the second phase screening evaluation will be done by someone other than the initial screener.

Initial screening will begin __________________________________________.

Please complete the bottom portion of this form and return it to school as soon as possible. If you have any questions, please do not hesitate to call me.

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School Nurse/School Nurse Practitioner

I, _____________________________________, hereby consent to the administration of a scoliosis screening test to my son/daughter, and I further acknowledge that I have read and understand the contents of this form.

______________________________________

Print Name of Son/Daughter and Grade

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Parent/Guardian Sinature