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Sickle Ced/Ns*S»Manat Anssssta terwwim Cwiik Fan* tom__ Date_ UrtMau --- ***•- - Spoua's Name or Parent's-—- ■■■ - ■ — ■ ■ ■ AddressPhone Horn* —— During day -- ®«* time «o callO 1. I hereby give my consent to be screened for sickle call and other hemoglobins by die Howard University Center for Sickle Ceil Disease □ J it Is my undemanding that the raaults obtained will be interpreted for me if I so desire □ J It is my understanding that the results of my tests will be held in strictest confidence unless I five written permission to release them □ 4. I hereby five the Howard University Center for Sickle Cell Disease permission to release the results of my, my child's sickle cell screening tests to only the following Dr. or Institution Address Sified __*PPt Scheduled - Relationship_Date Counseled -- Witness - Counselor _ ■ — Date Report Sent ■
The consent form reproduced above must be filled out
prior to examination for students, and will be
available at the high school. Minors not attending
school and wishing to be examined can obtain a form
at the Rappahannock News Office.
What And Where
For Arts Center?
50.4%