Greenbriar Community School

Health Screening Religious Exemption

State of Texas · 25 TAC §§37.23, 37.25, 37.144(e)

Student Name

Parent or Legal Guardian (Full Name)

Select screenings being declined

Vision Screening

Required at enrollment and annually through Grade 3, then in Grades 5, 7, and 9.

Hearing Screening

Required at enrollment and annually through Grade 3, then in Grades 5, 7, and 9.

Spinal Screening

Girls — at age 10 (Grade 5) and age 12 (Grade 7) Boys — at age 13 or 14 (Grade 8)

I understand that Texas law requires the above screenings for all students enrolled in public and private schools. I hereby request that the above-named student be exempt from the selected screening(s), as they conflict with the tenets and practices of our religious affiliation.

Signature of Parent or Legal Guardian

Date

Sign and submit to Greenbriar Community School · No notarization required
Texas DSHS · 25 TAC §§37.23, 37.25, 37.144(e)