DOH School Height/Weight Equipment Request Form

School Building Name *

District Name *

Name of Contact Person *

Telephone Number *

Email *

If approved, person and street address (not PO Box) to whom the equipment will be shipped to: *

Are you applying for a scale?

Yes

Is weight measured on a balance beam scale?

Yes

If no, how is weight obtained?

Is scale moved from location to location?

Yes

Where would this scale be located?

Would location allow for privacy when obtaining weight?

Yes

Why do you want a new scale?

Are you applying for a measuring board?

Yes

Is height measured on a wall-mounted measuring board?

Yes

If no, how is height obtained?

Where would this measuring board be located?

Why do you want a new measuring board?

Has this school participated in the height/weight data collection?

Yes

Would you be willing to participate if you received this equipment?

Yes

Approximately how many students would you measure each year?

School agrees to submit data for a minimum of 3 years if awarded the equipment. I declare under penalty of perjury under the law of South Dakota that the preceding is true and correct. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this form. *

I agree

By selecting "I agree" using any device, means, or action, I consent to this document's legally binding terms and conditions.

Date Signed *

Signature of Building Principal *

Type your name to sign.

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