Child Toothbrushing Consent Form
Please complete this form to provide your consent for your child to participate in a supervised toothbrushing program.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
School/Class or Group Name
*
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Other
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Does your child have any allergies or medical conditions we should be aware of? (e.g., toothpaste allergies, special needs)
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
By signing below, I confirm that I am the parent or legal guardian of the named child and give permission for my child to participate in the supervised toothbrushing program. I understand that staff will take appropriate precautions and will contact me in case of any concerns.
*
Submit Consent
Submit Consent
Should be Empty: