Request Student Screening

Step 1 -Personal Information

Please enter your personal information, in order to process the student screening report. All information must be accurate to complete a valid report.

Personal Information

Full Name

First Middle Last

Maiden Name (optional)

Former Last Name Only


Social Security Number


Date of Birth

Month Day YEAR

Email Address

Required for Immunization Records.

Current Address

Address 1 - Note: We cannot accept PO BOX addresses
Address 2 (optional)
City State Zip Code

School Information