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School Based Dental Program - Enrollment Form
2023-2024 South Seneca School
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* Indicates required question
Please complete this enrollment form even if your child is not going to participate as soon as possible, we are at the school for a limited time. Thank you, we look forward to visiting your school! You MUST complete a separate form for each child.
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Which school does your child attend?
*
Head Start
Elementary
Middle School
High School
What grade is your child in?
*
Head Start
Pre-K
Kindergarden
1
2
3
4
5
6
7
8
9
10
11
12
Who is your child's teacher?
*
Your answer
Do you want your child to participate in this program?
*
I DO
I DO NOT
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This form was created inside of Finger Lakes Migrant Health Care Project, Inc.
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