Vision Screening Consent Form
Your local Lions Club and KIDSIGHT South Dakota is offering a free vision screening to your child. The Screening is approximately 85-90% effective in detecting potential vision problems. No physical contact is made with your child and no eye drops are required. For more information go to www.kidsight.org
1. The information obtained from this vision screenign is preliminary only and does not constitute a complete exam or diagnosis of vision problems.
2. The Data obtained from this vision screening may be shared with entities participating in the vision screening, i.e. school nurse, Head Start, daycare provider, SD Lions Foundation, etc Results will be kept private and on file by the SD Lions Foundation including your child's name and date of birth.
3. I will receive the results of the screening through the Lions "KIDSIGHT" Preschool Vision Screening Program only if my child is being recommnded for a full eye exam.
4. I understand I am responsible for arranging a complete eye exam if my child has been referred as a result of the screening.
5. I may receive communication by telephone or emal if my child does not pass the vision screening for the purpose of evaluating the sucess of the program.
6. I will not hold SD Lions Foundation accountable for any errors of commission, omission or another misdiagnosis.
