Oral Health School Screening Form

All children in JK and SK will be screened on Oral Health Day at your child's school.

Please ONLY complete this form if:

you do not want your JK or SK child to receive a dental screening OR
you have a child in grades 1-8 who you would like to receive a dental screening by Halton Region Public Health.

*Indicates required field.

I do not want my child screened for oral healthI want my child screened for oral health

Oral health screening is available for children attending Junior Kindergarten (JK) or Senior Kindergarten (SK).

YesNo

School dental screenings are optional. If you do not wish for your child to participate, please contact us before the screening date by completing this form. If you exempt your child on or after the screening date, there is a chance that your child may have already been screened.

Please note that this list is not carried forward into future school years. If your child transfers to another school, it is your responsibility to inform the local Public Health Unit.

Before submitting the exemption form for your child, we encourage you to consider the many benefits of dental screening. For more information, please visit Halton.ca.

By completing and submitting this form, your child will be included in the school dental screening. A post-screening notification letter will be sent home with your child’s results.

Halton Region Public Health is required to follow up with children who have urgent dental needs to ensure they receive appropriate treatment.

Please note that oral health screenings do not replace a dental exam with a dentist.

Oral health screening is offered to children in JK or SK.

If your child is not in JK or SK, you do not need to continue with this form.

Children who are in JK or SK are automatically screened for oral health, you do not need to sign them up.

Which school board does your child attend?:*

Name of the school:*

Name of child:*

Child's first nameChild's last name

Child's grade:*

Child's grade

Teacher's name:

Teacher's name

Class:

Class

Parent/Guardian's name:*

Parent/Guardian's name

Parent/Guardian's phone number:*

Parent/Guardian's phone numberFormat: (000) 000-0000.

Parent/Guardian's email:*

Parent/Guardian's email

Add another child:

Name of child:*

Child's first nameChild's last name

Child's grade:*

Child's grade

Teacher's name:

Teacher's name

Class:

Class

Add another child:

Name of child:*

Child's first nameChild's last name

Child's grade:*

Child's grade

Teacher's name:

Teacher's name

Class:

Class

Add another child:

Name of child:*

Child's first nameChild's last name

Child's grade:*

Child's grade

Teacher's name:

Teacher's name

Class:

Class

Add another child:

Name of child:*

Child's first nameChild's last name

Child's grade:*

Child's grade

Teacher's name:

Teacher's name

Class:

Class

YesNo

Personal health information is collected on this form pursuant to the Health Protection and Promotion Act and will be used by Halton Region Public Health for navigating clients to dental care and with general program planning and administration. If you have any questions about the collection and use of your information, please visit halton.ca/privacy, or call 311 and ask to speak with the Manager of the Oral Health Program.