Uintah School District
435-781-3125
[email protected]
250 South Vernal Avenue
Vernal, Utah 84078

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I am the parent or legal guardian of this child with authority to make healthcare decisions for my child. By clicking submit, I agree to allow data entered through this electronic form to be stored in a secure database for my provider to review.

If I choose not to submit this and share my child’s screening data as stated above, I may request a paper screening option from my child’s provider.

I understand that signing this authorization is voluntary. I understand this authorization will expire upon my child's 18th birthday.

I understand that I may revoke this authorization at any time and the revocation does not apply to any action that has taken place prior to the date I revoke this authorization.

To revoke this authorization, I must make a request in writing and send it to: [email protected].

Note: By clicking "Submit", you are agreeing to both our Family Access End User License Agreement and any other consent or authorization information outlined on this page.