School Dental Screening Opt-In Form

If your child is not in a grade that is scheduled to be screened, you are still able to have your child receive a dental screening. To opt in to screening, you must contact us one of the following ways:

Complete the form below
Call 905-688-8248 or 1-888-505-6074 ext. 7399

Complete this form before the screening day. If your child switches schools during the school year, it's your responsibility to notify us.

* = Required

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

* School

* Current grade

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.

School Dental Screening Opt-In Form

Student Information

Notice of Collection

Public Health

Dental Health