Miles of Smiles Parent Permission Form

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Name of Your Child's School *

Child's Name *

Child's Grade *

Child's Date of Birth *

YYYY

Parent / Guardian Name

Address

Phone Number

Please choose which option you would like your child to receive.

Yes, I would like my child to receive fluoride varnish and a dental screening.

No, I would not like my child to receive fluoride varnish but, YES I would like them to receive a dental screening.

Clear selection

Does your child receive Medicaid/MCNA *

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