School Dental Screening Opt-Out Form

Student Information

* Student first name

* Student last name

* Parent / guardian first name

* Parent / guardian last name

* Phone
xxx-xxx-xxxx

* Parent / guardian email

* Student date of birth Year 2024202320222021202020192018201720162015201420132012201120102009200820072006 Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day 12345678910111213141516171819202122232425262728293031

* School

* Current grade Select one... Junior kindergarten Senior kindergarten Grade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8

* Reason I am not interested in my child participating: Select one... Child saw Dentist or Public Health Dental Professional recently Child has private dental insurance Child is enrolled in Healthy Smiles Ontario Child is nervous or anxious Not interested in Public Health services Prefer not to say Other
Choose the most applicable reason

* Other

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of Regional staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

For questions or comments about privacy practices, or for more information about the administration of the Municipal Freedom of Information and Protection of Privacy Act in Niagara Region programs, see Freedom of Information and Open Government.