SBCHC Health Needs Assessment Opt-Out

Middle and high school students at Horizon Community Middle School, Prairie Middle School, and Overland High School will be provided the option to complete a brief, anonymous survey asking for their input about health issues in their community and what types of health education topics they would like to learn more about through the health education programming that will be offered via the new STRIDE school-based community health centers. If you as a parent/guardian of students at any of these three schools would like to opt your child(ren) out of this survey, please complete the following form. Please note that even if your child does not participate, they will still be able to seek care at one of these school-based community health centers.

1. How many of your children would you like to opt-out of completing the school-based health center needs assessment survey? *This question is required.

2. What is the name of Student 1 that you would like to opt-out of completing the school-based health centers needs assessment survey? *This question is required.

3. What is the Cherry Creek email address of Student 1 you would like to opt-out of completing this survey? *This question is required. This question requires a valid email address.

4. Which school does Student 1 attend? *This question is required.

5. What is the name of Student 2 that you would like to opt-out of completing the school-based health centers needs assessment survey? *This question is required.

5. What is the Cherry Creek email address of Student 2 you would like to opt-out of completing this survey? *This question is required. This question requires a valid email address.

5. Which school does Student 2 attend? *This question is required.

5. What is the name of Student 3 that you would like to opt-out of completing the school-based health centers needs assessment survey? *This question is required.

5. What is the Cherry Creek email address of Student 3 you would like to opt-out of completing this survey? *This question is required. This question requires a valid email address.

5. Which school does Student 3 attend? *This question is required.

5. What is the name of Student 4 that you would like to opt-out of completing the school-based health centers needs assessment survey? *This question is required.

5. What is the Cherry Creek email address of Student 4 you would like to opt-out of completing this survey? *This question is required. This question requires a valid email address.

5. Which school does Student 4 attend? *This question is required.

5. What is the name of Student 5 that you would like to opt-out of completing the school-based health centers needs assessment survey? *This question is required.

5. What is the Cherry Creek email address of Student 5 you would like to opt-out of completing this survey? *This question is required. This question requires a valid email address.

5. Which school does Student 5 attend? *This question is required.

5. Your Name: *This question is required.

6. Your Email Address: *This question is required. This question requires a valid email address.

SBCHC Health Needs Assessment Opt-Out

School-Based Health Center Needs Assessment Survey Opt-Out Form