2025 Fall Games Healthy Athletes Screening Questions
We are very excited to offer 2 Healthy Athletes Screenings at our 2025 Fall Games! These screenings are: Special Smiles (Dental/Oral Health) and Health Promotion (Preventative Health).
This form has closed to prepare for the 2025 Fall Games and Healthy Athletes Screenings. Please bring 2 completed forms to Healthy Athletes at the 2025 Fall Games. If you need the form, please email Alex Gilman at agilman@vtso.org
Athlete Information
Athlete Name
*
First Name
Last Name
Athlete Date of Birth
*
-
Month
-
Day
Year
Date
Delegation
*
Addison
Bellcate
Bennington
Caledonia
Capital Region
Castleton
Central Vermont
Chittenden
Franklin
Northshire
Orleans Essex
Randolph
Rutland
Windham
Other
Best Phone Number to Contact
*
Please enter a valid phone number.
If not athlete's phone number, please provide name and relationship to athlete
Best Email to Contact
*
example@example.com
If not athlete's email, please provide name and relationship to athlete
Best Address to Send Athlete Information
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Special Smiles (Dental/Oral Health)
Do you have a local dentist?
*
Yes
No
How often do you visit your local dentist?
More than twice a year
Twice a year
Once a year
Less than once a year
Only when I have a toothache
Do you play a contact sport (for example: basketball, floorball, soccer)?
*
Yes
No
If a dental screener thinks you would benefit from a fluoride application to protect your teeth, would you agree to receive this care?
*
Yes
No
Submit
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