2023/2024 Back to School Fair Registration Form

Platte County Back to School Fair 2023/2024 School Year

The 2023 Back to School Fair will be on August 3, 2023. Registration deadline is July 28, 2023. Please note appointment reminders will be emailed.
Well-Child exams, vision and dental screenings, immunizations and sports physicals will be available the day of the event. *If your child needs a sports physical or immunization please fill out the needed forms (link to forms located on registration page and at the end of this registration).

Please bring shot records for well-child exams and sports physical appointments.

NEW LOCATION:

7925 NW 110th St, Kansas City, MO 64153

New location is on the bus line.
Parent Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone 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?*
Child's Name (First & Last)*
Child's Gender*
Child's Date of Birth*

MonthDayYear
Date
Child's Age (years)*
Ethnic/Racial Background*
Child's Grade for 2023/2024 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 treatmentEye ScreeningWell-Child ExamSports PhysicalImmunizationsNone
Child's Health Insurance Plan*
Type a question
Please allow 1 - 1.5 hours for all appointments

Last appointment time available for physicals is 3:30 p.m.

If registering for a sports physical please fill this form out.

Physical Registration Form

If registering for immunizations please fill this form out.

Immunizations Registration Form
Appointment*
Do you have another child to register?*

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

MonthDayYear
Date
Child's Age (years)*
Ethnic/Racial Background*
Child's Grade 2023/2024 School Year*
Last appointment time for physicals is 3:30 p.m.

Please bring your child's shot records for well-child exam and sports physical appointments.
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 treatmentEye ScreeningWell-Child ExamSports PhysicalImmunizationNone
Child's Health Insurance Plan*
Do you have another child to register?*

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

MonthDayYear
Date
Child's Age (years)*
Ethnic/Racial Background*
Child's Grade for 2023/2024 School Year*
Last appointment time for physicals is 3:30 p.m.

Please bring your child's shot records for well-child exam and sports physical appointments.
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 treatmentEye ScreeningWell-Child ExamSports PhysicalImmunizationsNone
Child's Health Insurance Plan*
Do you have another child to register?*

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

MonthDayYear
Date
Child's Age (years)*
Ethnic/Racial Background*
Child's Grade for 2023/2024 School Year*
Last appointment time for physicals is 3:30 p.m.

Please bring your child's shot records for well-child exam and sports physical appointments.
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 treatmentEye ScreeningWell-Child ExamSports PhysicalImmunizationsNone
Child's Health Insurance Plan*
Do you have another child to register?*

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

MonthDayYear
Date
Child's Age (years)*
Ethnic/Racial Background*
Child's Grade for 2023/2024 School Year*
Last appointment time for physicals is 3:30 p.m.

Please bring your child's shot records for well-child exam and sports physical appointments.
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 treatmentEye ScreeningWell-Child ExamSports PhysicalImmunizationsNone
Child's Health Insurance Plan*
Do you have another child to register?*

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

MonthDayYear
Date
Child's Age (years)*
Ethnic/Racial Background*
Child's Grade for 2023/2024 School Year*
Last appointment time for physicals is 3:30 p.m.

Please bring your child's shot records for well-child exam and sports physical appointments.
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 treatmentEye ScreeningWell-Child ExamSports PhysicalImmunizationsNone
Child's Health Insurance Plan*
Do you have another child to register?*

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

MonthDayYear
Date
Child's Age (years)*
Ethnic/Racial Background*
Last appointment time for physicals is 3:30 p.m.

Please bring your child's shot records for well-child exam and sports physical appointments.
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 treatmentEye ScreeningWell-Child ExamSports PhysicalImmunizationsNone
Child's Health Insurance Plan*
Child's Grade for 2023/2024 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

Clear
If registering for a sports physical please fill this form out.

Physical Registration Form

If registering for immunizations please fill this form out.

Immunizations Registration Form
Should be Empty:

Platte County Back to School Fair 2023/2024 School Year

Electronic Signature