Dental Health Registration Survey- RS

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* Child First Name

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* Child Last Name

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* My child identifies as

Male

Female

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* Does your child identify as African American?

Yes

No

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* Does your child identify as Hispanic?

Yes

No

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* What is your email address? This will not be shared.

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* What is your zip code?

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* How old is your child?

0-1 yr old

2-5

6-9

10-13

14-16

17-18