HUI HELEUI: NIGHTMARE ON MAHALANI STREET
Aloha,
If you are on this page that means you are interested in having your child/children receive free dental treament at the Hui Heleui: Nightmare on Mahalani Street event on Saturday, October 29th 2022 from 4pm to 8pm. By doing this form, it will help us get your child/children in to the dental clinic quicker. See you there! :) 
NOTE- 1 form per child
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Email *
Child's Name  *
Child's Age *
To which gender identity does your child identify most?  *
Child's parents/legal guardian name and best contact phone number. Also, please state best form of communication: text or call. 
*Please note this information will be used to schedule your child to come to the dental clinic at a certain time* 
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I am the parent or legal guardian of the child whose name appears above. I hereby give permission for such a child to receive dental treatment with Hui No Ke Ola Pono. I understand and agree that dental treatment is being conducted at no cost and that I am participating voluntarily. I hereby agree to release and discharge all parties involved, including without limitation the dental professionals who are conducting treatment, from any and all liabilities, suits, costs or expenses in any way relating to the participation of the child below.


NOTE: If we find any teeth that needs any restorative treatment (fillings, sealants) we will ask for a parent/legal guardian consent before proceeding.

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Please answer the next questions to help us learn more about access to dental care.  Your answers will remain private and will not be shared.  If you do not want to answer the questions, you may still give permission for your child to have his or her teeth checked.

Would you like to answer the following questions to help us learn more about access to dental care?  *

During the past 6 months, did your child have a toothache more than once, when biting or chewing?

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How long has it been since your child last visited a dentist? Include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists. (Check one)

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What was the main reason that your child last visited a dentist? (Check one)
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During the past 12 months, was there a time when your child needed dental care but could not get it?

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The last time your child could not get the dental care he/she needed, what was the main reason he/she couldn’t get care? (Check one)

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Do you have any kind of insurance that pays for some or all of your child’s DENTAL CARE? Include health insurance obtained through employment or purchased directly, as well as government programs like Medicaid or CHIP? 

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Which of the following best describes your child? (Check all that apply)

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Required
Is your child eligible for the free or reduced price lunch program?
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