ScreeningSubmission - Student Health Screening Registration

West Bloomfield High School
4925 Orchard Lake Rd, West Bloomfield, MI 48323

Please complete the form below:

Find and select your time slot.

Student First Name

Student Last Name

Gender

Student School

Student Birthday (mm/dd/yyyy)

Parent or Guardian Full Name

Parent or Guardian Email

Parent Phone Number

Address Line 1

Address Line 2

City

State

Zip Code

Comments

How did you hear about our program?

Notes

Minimum age is 13 for this screening. We can not accommodate younger students