Request Student Screening

Step 1 -Personal Information

Please enter your personal information, in order to process the student screening report. All information must be accurate to complete a valid report.

Personal Information

Full Name
First Middle Last

Maiden Name (optional)
Former Last Name Only

Gender

Social Security Number
  XXX-XX-XXXX

Date of Birth
Month Day YEAR

Email Address
Required for Immunization Records.

Current Address

Address 1 - Note: We cannot accept PO BOX addresses
Address 2 (optional)
City State Zip Code

School Information

School

Program