ࡱ> VXU` =bjbjss 8Hc F F F 8~ L \)2!2!2!2!2!f"f"f"l(n(n(n(n(n(n($ *hq,(Ej$f"f"j$j$(2!2!4( & & &j$X2!2!l( &j$l( & & &2!&! 0LQF $X &x'(0) &=/%=/ &=/ &lf"v"T &0#Dt#f"f"f"((%Xf"f"f")j$j$j$j$  Manteca Unified School District Oral Health Assessment/Waiver Request Form California law, Education Code Section 49452.8, now requires that your child have an oral health assessment prior to school entry. The law specifies that the assessment must be performed by a licensed dentist or other licensed or registered dental health professional. Oral health assessments that have happened within the 12 months before your child enters school also meet this requirement. If you cannot take your child for this assessment, you may be excused from this requirement by filling out Section 3 of this form. Section 1 To be completed by the parent or guardian Childs First Name: Last Name:Middle Initial:Childs birth date:Address: Apt.: City: ZIP code:School Name: Teacher:Grade:Childs Gender: % Male % FemaleParent/Guardian Name:Child s race/ethnicity: % White % Black/African American % Hispanic/Latino % Asian % American Indian % Alaska Native % Native Hawaiian/Pacific Islander % Multi-racial % Unknown  Section 2 Oral Health Data Collection To be completed by the dental professional conducting the assessment Assessment Date:Visible fillings present: % Yes % NoVisible caries present: % Yes % NoTreatment Urgency: % No obvious problem found % Early dental care recommended % Urgent care needed ______________________________________________________________________ Dental professional s signature Date Section 3 Waiver of Oral Health Assessment Requirement To be completed by a parent or guardian requesting to be excused from this requirement I request that my child be excused from the oral health assessment requirement for the following reason: (Please check the box that best describes the reason.) !7FKLM[]k|q      ö}s}i}\O\}EEhfpOJQJ^JhC9h|7MOJQJ^JhC9hLOJQJ^JhbOJQJ^Jhw]OJQJ^JhFVOJQJ^Jhjhj6OJQJ^JhjOJQJ^JhC9hOJQJ^JhGOJQJ^JhC9hGOJQJ^JhEh5CJ OJQJ^JaJ hw]5CJ OJQJ^JaJ h-!5CJ OJQJ^JaJ hfp5CJ OJQJ^JaJ !LMY Z d $IfgdL- gdL- $a$gdL- ^gd%gd$a$gdG := A J W X Y Z d      ñvlv[lvlQlv[DDDhC9hLOJQJ^Jhh%OJQJ^J hC9h-!CJOJQJ^JaJh-!OJQJ^JhC9h-!OJQJ^J hC9hL- CJOJQJ^JaJhC9hL- OJQJ^JhC9hL- 5>*OJQJ^J#h%hL- 5CJOJQJ^JaJhh%5OJQJ^JhC9h5OJQJ^JhC9hXOJQJ^JhfpOJQJ^JhC9hOJQJ^J ^UUUU $IfgdL- kd$$Ifl\ D%  p t0&644 la {{{ $IfgdL- zkd$$Ifl0D%<p t0&644 la     '  {{{{rrr $IfgdL $IfgdL- zkd$$Ifl0D%<p t0&644 la   " . B ~     8 : < \ ^ | *,.0@BDFH󾴧󴧝󧝴󧴝󧴧󝧝Ւhh%5OJQJ^JhLhOJQJ^JhC9h\TOJQJ^Jhh%OJQJ^JhC9hAwOJQJ^JhC9OJQJ^J hC9hL- CJOJQJ^JaJhC9hLOJQJ^JhC9hL- OJQJ^J2 " N .D^UUHUU $IfgdLh $IfgdL- kdX$$Ifl\ D%  p t0&644 laDFH\ Bv||tttkbbbb $Ifgd` $IfgdL- $a$gdL- $a$gdXzkd$$Ifl0 D%  t0&644 la H4>BPrvzV^иЪtМjYNhh%5OJQJ^J hC9hL- CJOJQJ^JaJhfpOJQJ^JhC9hU{>*OJQJ^JhC9h OJQJ^JhC9h`OJQJ^JhC9h`>*OJQJ^JhC9h >*OJQJ^JhQ[>*OJQJ^JhC9hJIOJQJ^JhC9hL- OJQJ^JhC9hL- 5>*OJQJ^J#h%hL- 5CJOJQJ^JaJ0Xv$7$8$H$If^`gdfp $7$8$H$IfgdC9 $Ifgd` $7$8$H$Ifgd`4^VVVQVVVVgdL- $a$gdL- kdL$$Ifl\ D%c  t0&644 la 24BDrJȻȫȠm]M=]hC9h]5>*OJQJ^JhC9hJI5>*OJQJ^JhC9hL- 5>*OJQJ^J#h%hJI5CJOJQJ^JaJhw]5CJOJQJ^JaJ#h%hL- 5CJOJQJ^JaJhEh5OJQJ^JhC9h]-Q56OJQJ^Jhfp56OJQJ^JhC9hL- 56OJQJ^JhC95OJQJ^JhC9hL- 5OJQJ^JhC9hA5OJQJ^J.z~4>4^444444455F5H5J5n5ʽ䩜䜃vlblXh'DOJQJ^JhkCOJQJ^JhLhOJQJ^JhC9hP\OJQJ^JUh#vOJQJ^JhC9hXOJQJ^JhC9hr7OJQJ^JhEhOJQJ^Jhw]OJQJ^JhC9hJIOJQJ^JhC9hOJQJ^JhC9ha OJQJ^JhC9hL- OJQJ^JhC9hL- >*OJQJ^J 455666677777778,: <$IfgdfpgdL- ^gd%% I am unable to find a dental office that will take my child s insurance plan. My child is covered by the following insurance plan: % Medi-Cal/Denti-Cal % Healthy Families % Healthy Kids % None % Other __________________________________ % I cannot afford an oral health assessment for my child. % I do not wish my child to receive an oral health assessment. Optional: other reasons my child could not get an oral health assessment: California law requires schools to maintain the privacy of students health information. Your child s identity will not be associated with any report produced as a result of this requirement. If you have any questions about this requirement, please contact your school office.  Signature of parent or guardian Date     January 2007 California Department of Education Return this form to the school with Kindergarten Registration Original to be retained in child s school record. Page 2 of 2 Return this form to the school with Kindergarten Registration Original to be retained in child s school record. 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