(K-8) Hearing/Vision Screening Release Form (2026-2027)

Family Education Rights & Privacy Act Educational

Records Release Form for Hearing/Vision Screening
Student Name - Prefill

First NameLast Name
Parent Name = Prefill

First NameLast Name
The Forrest City School District conducts vision and hearing screenings for kindergarten, 1st, 2nd, 4th, 6th, and 8th grades, as well as transfer students and students being referred or reevaluated for IDEA or 504 purposes, each year as required by Arkansas law. You are notified if your child does not pass the screening. By providing the requested information below, the District may be eligible for reimbursement from Medicaid/AR Kids. Your consideration and response are appreciated. Please return the completed form to your child’s school.

In compliance with the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99)
I, Parent/Guardian First Name* Parent/Guardian Last Name* (Parent/Guardian Name), permit my child,
Student First Name* Student Last Name* 's (First and Last Name) printed personally identifiable information/student education record/vision and hearing screening results to be disclosed to a Third party for billing /auditing Medicaid/AR Kids for reimbursement for vision and hearing screening.
Name of Parent/Guardian
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Full Name
School
Grade
Should be Empty:

Family Education Rights & Privacy Act Educational