School Dental Screening Non-Participation Form

Student Information

* Student first name

* Student last name

* Parent / guardian email

* Student date of birth Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day 12345678910111213141516171819202122232425262728293031 Year 2022202120202019201820172016201520142013201220112010200920082007200620052004

* School

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

Personal Information and Privacy

Any personal information or personal health information submitted in writing will be collected, used and disclosed by members of Regional Council and Regional staff in accordance with the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, where applicable.

Freedom of Information

Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email our Access and Privacy Office or call 905-980-6000 ext. 3779.