Emery County Preschool - USBE Pre-K 435-749-0216[email protected]120 N. Main St.PO Box 120Huntington, Utah 84528
Weeks Premature (put "0" if not premature)
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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].
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