Cass Community Health Foundation Dental Screening Volunteers

Pleasant Hill Elementary

327 N. McKissock, St., Pleasant Hill, MO 64080

Friday, September 13, 2024
AM Shift: 8:30 AM - 11:00 AM

PM Shifts: 11:30 AM - 2:30 PM

Conn-West Elementary

1100 High Grove Rd., Grandview, MO 64030

Friday, September 20, 2024
AM Shift: 9 AM - NOON
PM Shift: 12:15 - 3 PM

East Lynne Elementary

24706 S, State Hwy K, East Lynne, MO 64743

Friday, September 27, 2024

8:00 AM - 12:00 PM

Butcher-Greene Elementary

5302 E. 140th St., Grandview, MO 64030

Friday, October 4, 2024
9 AM - 12:15 PM

Harrisonville Elementary

101 Meghan Rd., Harrisonville, MO 64701

Wednesday, October 9, 2024
AM Shift: 9 AM - 12:20 PM

PM Shift: 12:40 - 3:15 PM

Mill Creek Upper Elementary

308 S. Cleveland, Belton, MO 64012

Friday, October 11, 2024
8:45 AM - NOON

Concorde Career Dental Hygiene Student Event

Kentucky Trail Elementary

8301 E. 163rd St., Belton, MO 64012

Friday, October 11, 2024
12:15 PM - 3:30 PM

Concorde Career Dental Hygiene Student Event

Wilckens STEAM Academy at Hillcrest

106 S. Hillcrest Rd., Belton, MO 64012

Friday, October 18, 2024

AM Shift: 9 AM - NOON

PM Shift: 12:30 - 3:45 PM

UMKC Division of Dental Hygiene Student Event

Meadowmere Elementary

7010 E. 136th St., Grandview, MO 64030

Wednesday, October 23, 2024

AM Shift: 9:15 AM - NOON

PM Shift: 12:30 - 3:15 PM

Pleasant Hill Primary School

304 Eklund St, Pleasant Hill, MO 64080

Friday, November 1, 2024

8 AM - 12:30 PM

Harrisonville Early Childhood Center

500 Polar Lane, Harrisonville, MO 64701

Thursday, November 7, 2024
9 AM - 12:15 PM

McEowen Elementary

1901 S. Halsey, Harrisonville, MO 64701

Thursday, November 7, 2024
12:45 - 3 PM

Pleasant Hill Elementary

327 North McKissock St. Pleasant Hill, MO 64080

Thursday, November 14, 2024

12:45 PM -3:00PM

Belvidere Elementary

15010 White Ave., Grandview, MO 64030

Friday, November 15, 2024

9 AM - NOON

Grace Early Childhood Center

614 Mill St., Belton, MO 64012

Wednesday, November 20, 2024

AM Shift: 8:45 - 11:30 AM

PM Shift: 12:45 - 3:30 PM

Pleasant Hill Intermediate

1204 East 163rd St. Pleasant Hill, MO.

Wednesday, December 4th, 2024

AM Shift: 8:45 - 11:45 AM

PM Shift: 12:15 - 3:30 PM

Butcher-Greene Elementary

5302 E 140 St, Grandview, MO 64030

Wednesday, December 11th, 2024

AM Shift: 9:00AM -12:15PM

Cass County Elementary

302 W. State Route A, Archie, MO 64725

Friday, December 13th, 2024

AM Shift: 8:30 - 11:30 AM

PM Shift: 12:45 - 3 PM

Please list dental credentials here, if applicable.

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

E-mail*

example@example.com

HIPPA / CONFIDENTIALITY AGREEMENT: By selecting "I Agree" below, I understand that any information (written, verbal, or other) obtained during the performance of my volunteer duties must remain confidential. This includes all information about students, members, patients, families, employees and other associate organizations, as well as any other information otherwise marked or known to be confidential. This includes all Protected Health Information defined by the Health Insurance Portability and Accountability Act (HIPAA) and any individually identifiable information, including student name, insurance status, treatment rendered, and all information pertaining to previous or existing health conditions or treatment needs, and any other information that may be used to identify an individual. I understand that any unauthorized release or carelessness in the handling of this confidential information is considered a breach of duty to maintain confidentiality. I further understand that any breach of the duty to maintain confidentiality could be grounds for immediate dismissal and/or possible liability in any legal action arising from such breach.*

I Agree

MEDIA RELEASE: I hereby consent that any photographs/video/audio taken of me by Cass Community Health Foundation may be used by them or assignees for the purpose of illustration, teaching, web content, publicity or publication in any form. NOTE: If you do not want to be photographed, please also remind the Cass County Dental Clinic employee who is present at each dental screening event.*

YesNo

Have you ever been convicted of a felony or misdemeanor?*

YesNo

If YES, describe your conviction.

By signing below, I certify that I am at least 18 years old. I have completed this form accurately and on my own behalf.

Signature*