2022/2023 Back to School Fair Registration Form

Platte County Back to School Fair 2022/2023 School Year

The 2022 Back to School Fair will be on August 4th. Registration deadline is July 20, 2022. Appointment card will be mailed out after registration closes.
Well-Child exams, vision and detal screenings, and sports physicals will be available the day of the event. *If your child needs a sports physical please bring completed form with you (link to form is located on registration page).*
Parent Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Parent E-mail Address *
example@example.com
What is the household means of income? Select all that appy. *
What is the households total monthly wages? *
Does your houshold receive food stamps? *
Child's School District *
Which does your child qualify for? *
Childs Name (First & Last) *
Child's Gender *
Child's Date of Birth *

Month Day Year
Date
Child's Age (years) *
Ethnic/Racial Background *
Child's Grade for 2022/2023 School Year *
Will your child be receiving any of the following services at the Back to School Fair? Please select all that apply. *

Dental Screening with fluoride treatment Eye Screening Well-Child Exam Sports Physical None
Child's Health Insurance Plan *
Appointment *
Do you have another child to register? *

Childs Name (First & Last) *
Child's Genger *
Child's Date of Birth *

Month Day Year
Date
Child's Age (years) *
Ethnic/Racial Background *
Child's Grade for 2022/2023 School Year *
Will your child be receiving any of the following services at the Back to School Fair? Please select all that apply. *

Dental Screening with fluoride treatment Eye Screening Well-Child Exam Sports Physical
Child's Health Insurance Plan *
Do you have another child to register? *

Childs Name (First & Last) *
Child's Genger *
Child's Date of Birth *

Month Day Year
Date
Child's Age (years) *
Ethnic/Racial Background *
Child's Grade for 2022/2023 School Year *
Will your child be receiving any of the following services at the Back to School Fair? Please select all that apply. *

Dental Screening with fluoride treatment Eye Screening Well-Child Exam Sports Physical
Child's Health Insurance Plan *
Do you have another child to register? *

Childs Name (First & Last) *
Child's Genger *
Child's Date of Birth *

Month Day Year
Date
Child's Age (years) *
Ethnic/Racial Background *
Child's Grade for 2022/2023 School Year *
Will your child be receiving any of the following services at the Back to School Fair? Please select all that apply. *

Dental Screening with fluoride treatment Eye Screening Well-Child Exam Sports Physical
Child's Health Insurance Plan *
Do you have another child to register? *

Childs Name (First & Last) *
Child's Genger *
Child's Date of Birth *

Month Day Year
Date
Child's Age (years) *
Ethnic/Racial Background *
Child's Grade for 2022/2023 School Year *
Will your child be receiving any of the following services at the Back to School Fair? Please select all that apply. *

Dental Screening with fluoride treatment Eye Screening Well-Child Exam Sports Physical
Child's Health Insurance Plan *
Do you have another child to register? *

Childs Name (First & Last) *
Child's Genger *
Child's Date of Birth *

Month Day Year
Date
Child's Age (years) *
Ethnic/Racial Background *
Child's Grade for 2022/2023 School Year *
Will your child be receiving any of the following services at the Back to School Fair? Please select all that apply. *

Dental Screening with fluoride treatment Eye Screening Well-Child Exam Sports Physical
Child's Health Insurance Plan *
Do you have another child to register? *

Childs Name (First & Last) *
Child's Genger *
Child's Date of Birth *

Month Day Year
Date
Child's Age (years) *
Ethnic/Racial Background *
Will your child be receiving any of the following services at the Back to School Fair? Please select all that apply. *

Dental Screening with fluoride treatment Eye Screening Well-Child Exam Sports Physical
Child's Health Insurance Plan *
Child's Grade for 2022/2023 School Year *
Do you have another child to register? *

Electronic Signature

I certify that in the information provided to the Platte County Back to School Fair Association and its partners the YMCA of Greater Kansas City and the Platte County Health Department is true and accurate to the best of my knowledge. I understand that such information is subject to verification and I further realize that falsified or fraudulent information may result in rejection of my application. Please type parent's name in box to complete electronic signature.I hereby consent to and authorize the Platte County Back To School Fair Association, the Platte County Community Centers, and anyone authorized by them to take photos of my child/children for publicity purposes while in attendance of the Back To School Fair. Furthermore, my name will be shared with our community partners to schedule health screenings.*Presented by the Platte County Back To Fair Association and our community partners; Platte County Community Centers, operated by the YMCA of Greater Kansas City, and the Platte County Health Department.
Signature

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