School Based Dental Program

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.

Which school does your child attend? *

Roosevelt Children's Center

Student's First Name *

Student's Last Name *

What grade is your child in? *

Pre-K

Kindergarden

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Who is your child's teacher? *

Do you want your child to participate in this program? *

I DO

I DO NOT