Presented in partnership with the Allen County Department of Health

Virtual School Health Screening Day

Step 1 of 6 - Event

16%

March 13th 4pm-7pm

Hosted by Super Shot at 1515 Hobson Rd Fort Wayne, IN, 46805 :

Please complete each section and click 'Next'

Are you an Allen County resident?(Required)

Yes

This specific event is for Allen County residents only but most of these providers see patients outside of the county as well. Please reach out to the service providers directly if interested in services outside of Allen County. Thank You

Does your child attend a fully virtual school?(Required)

Yes

Only students who are registered as students in full virtual programs are eligible for this event. Please check back with us for other events if your child does not attend a virtual school!

Name of Virtual School(Required)

Virtual School Contact Number:(Required)

Date child started attending this Virtual school:(Required)

MM slash DD slash YYYY

Child's Name(Required)

First Middle Initial Last

Child's Date of birth(Required)

Month

Day

Year

Child's Grade for 2024-2025 School Year(Required)

Sex(Required)

Contact Information:

Parents/Guardians(Required)

First Name

Middle Initial

Last Name

Address(Required)

City(Required)

State(Required)

Zip(Required)

Mobile Phone Number(Required)

Email Address(Required)

Contact Preference(Required)

Do you have any concerns about your child having a vision deficit?(Required)

Yes

Do you have any concerns about your child having a hearing deficit?(Required)

Yes

Would you like your child to have a dental screening conducted by School Smiles?(Required)

Yes

Dental screening paperwork must be completed by February 10th to be registered. Additional paperwork may be sent to you via email and you will be contacted with reminders if the paperwork isn't completed.

Would you like your student to have a hearing screening by the Indiana Department of Health?(Required)

Yes

IDOH Mobile Hearning Services Consent(Required)

I am the parent/guardian of the named child above and I give consent for the Indiana Department of Health mobile unit to complete an audiologic screening. I have read and understand the contents of this permission for service consent. I understand that information obtained during the screening will be shared with me and I am responsible for making sure any follow-up care is obtained for my child. This consent is effective from the date of my signature on this form through the date of the screening exam. I HAVE READ THE DESCRIPTION BELOW AND UNDERSTAND THE CONDITIONS OF THIS FORM.

This consent is for the Indiana Department of Health (IDOH) mobile unit services to provide audiologic (hearing) screening for your child. Your child will receive a basic hearing screening using a headset and listening for different tone signals administered by the screening team. The screening is non-invasive and painless. IDOH recommends that any child with a failed screening follow up with their healthcare provider. If your child fails the screening, you are encouraged to schedule a follow-up evaluation with your child’s healthcare provider.
Results of the hearing screening will be provided to you to share with your child’s healthcare provider.
If you have any questions regarding the results of the hearing screening, please follow up with your child’s healthcare provider

Would you like your student to have a vision screening by Lions Club International?(Required)

Yes

Do you have any children in your home younger than 7 who you'd like to receive lead testing?(Required)

Yes

Testing and results are free and received at time of service by the Allen County Department of Health.

Would you like your student to receive vaccine services from Super Shot?(Required)

Yes

Do you have a second student to add to the form?(Required)

Yes

Second Child's Name(Required)

First Middle Initial Last

Sex(Required)

Second Child's Date of Birth(Required)

Month

Day

Year

2nd Child's Grade for 2024-2025 School Year(Required)

Do you have any concerns about your second child having a vision deficit?(Required)

Yes

Do you have any concerns about your second child having a hearing deficit?(Required)

Yes

Would you like your child to have a dental screening conducted by School Smiles?(Required)

Yes

Would you like your 2nd student to have a hearing screening by the Indiana Department of Health?(Required)

Yes

IDOH Mobile Hearning Services Consent(Required)

Would you like your student to have a vision screening by Lions Club International?(Required)

Yes

Would you like the 2nd student to receive vaccine services from Super Shot?(Required)

Yes

Do you have a third student to add to the form?(Required)

Yes

3rd Child's Name(Required)

First Middle Initial Last

Sex(Required)

3rd Child's Date of birth(Required)

Month

Day

Year

3rd Child's Grade for 2024-2025 School Year(Required)

Do you have any concerns about your 3rd child having a vision deficit?(Required)

Yes

Do you have any concerns about your 3rd child having a hearing deficit?(Required)

Yes

Would you like your 3rd child to have a dental screening conducted by School Smiles?(Required)

Yes

Would you like your 3rd student to have a hearing screening by the Indiana Department of Health?(Required)

Yes

IDOH Mobile Hearning Services Consent(Required)

Would you like your 3rd student to have a vision screening by Lions Club International?(Required)

Yes

Would you like your 3rd student to receive vaccine services from Super Shot?(Required)

Yes

Please Select an Arrival Time on 3/13/25(Required)

Communication(Required)

It's ok to call me

It's ok to TXT me

As the parent or guardian, I have legal authority to consent for all services rendered. I consent to my children, named above, to receive services from Super Shot and named partners above. I am aware of the HIPAA Notice of Privacy Policy available at supershot.org. I am aware and understand the CDC Vaccine Information Statements for any vaccines received are available at https://www.cdc.gov/vaccines/hcp/vis/index.html Information provided may be used to communicate with healthcare providers or other entities as needed for: data entry, billing, vaccination record inquiries, and data storage according to Indiana Department of Health policies. By signing below I agree to the services selected above.

Signature(Required)

Parent/Guardian Name(Required)

Date(Required)

MM slash DD slash YYYY

Phone

This field is for validation purposes and should be left unchanged.

Virtual School Health Screening Day

March 13th 4pm-7pm

Hosted by Super Shot at 1515 Hobson Rd Fort Wayne, IN, 46805 :

Contact Information:

Thanks to our community partners