Annual Screening Consent Form

Fillable Form Permission Slip for Computer

An annual school screening consent form is collected from parents/guardians at the beginning of each school year for our annual school screenings. Students must have a completed consent form in order to be screened for A1c (test that measures our average blood sugar level over the previous 3 month period).


Completed forms should be sent to the Fort Berthold Diabetes Program (1058 College Drive, New Town, ND 58763), faxed to 701-627-3913, or dropped off at the Diabetes Program office/Awatii Wellness Center.

Awatii Wellness Center

Awatii Wellness Center Guest Waiver

Health History Questionnaire