Dental Screening and Assessment — For children up to 7 years

Thank you for participating in community-engaged oral health systems dental screening.

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* 1. Parent's Name

Full Name

Phone Number

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* 2. Email

Please enter your email

Please confirm your email

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* 3. How many children will be participating in this screening?

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* 4. What are the names (first, middle initial, last) and ages of the participating children?

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* 5. Would you like to to be added to the First 5 Siskiyou mailing list to receive information about upcoming events, classes, and resources for families?

Yes

Already on the list

No, thank you