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Central Day School

2005 Winchester Blvd.

Collierville, TN 38017

(901) 255-8134

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Vision Screening Permission Form

September 16, 17, and 18, your child will have the opportunity to be screened for visual and ocular motility (muscle-imbalances) problems. The screenings will be performed by the staff of Carl E. Flinn, M. D., who specializes in Pediatric Ophthalmology and Strabismus. This is a basic screening which involves reading an eye chart and looking at pictures. The screening is provided at no cost.

If any abnormalities are found, the child will receive an examination form stating the possible problem and the need for referral to an optometrist or ophthalmologist of your choice.

This screening is optional and is not meant to take the place of your annual vision screening with your family eye doctor.

Please complete the form below and submit before Monday, September 14.   Children who do not submit a permission form will not participate in the screening. 

Student First Name
Student Last Name
Student's Age
Home Phone
Teacher
Parent's Name
Date
Please answer the simple math question below to submit the form.
2 + 2 =
verse Jeremiah 29:11
<BACK TO TOP> Central Day School is a ministry of Central Church | Ernie H. Frey, Senior Pastor

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