ScreeningSubmission - Student Health Screening Registration

Rochester High School
1361 Walton Blvd., Rochester Hills, MI 48309

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

Screening is limited to ages 13 and above. We can not accept younger students.