Clone of (Original-copy only)Template of Webinar registration

Do you have any dental insurance?你是否持有任何牙科保險?*

Yes 是No 否
Which of the following schemes are you enrolled in? 你參與以下那一個計劃？*

Ontario Works (OW)安省就業援助計劃Non-Insured Health Benefits (NIHB)非保險健康福利計劃Ontario Disability Support Program (ODSP)安省傷殘人士支援計劃Ontario Seniors Dental Program (OSDP)安省長者牙科護理計劃Interim Federal Health Program(IFHP) 臨時聯邦醫療計劃
清晰證明照片或文件 Clear image of card or document*

Either Ontario Works (OW) or Non-Insured Health Benefits (NIHB) or Ontario Disability Support Program (ODSP) 安大略省殘障支援計劃 or Ontario Seniors Dental Program (OSDP) 安省長者牙科保健計劃 or Interim Federal Health Program (IFHP) 聯邦臨時醫療保險
Cancelof

Pre-service needs assessment 服務前需要評估

In order to streamline the registration process, if you have previously received our services and completed the pre-service needs assessment, you may skip the assessment section. Otherwise, please take a few minutes to complete it so that we can provide services and activities best suited to your needs. Thank you!為了簡化登記流程，若你在2025年4月1日至今日曾報名參加我們的服務，又填寫過服務前需要評估，我們會為你略過評估；相反，我們邀請你花時間完成以下評估，以便我們能為你提供更適合的活動及服務，感謝！
Did you previously receive our services and complete the pre-service needs assessment? 你是否在2025年4月1日至今日曾報名參加我們的服務，又填寫過服務前需要評估？*

Yes 是No 否

Consent 同意
I hereby acknowledge the following in relation to my participation in services provided by Community Family Services of Ontario (CFSO). 本人特此確認，本人參加由家和提供的服務時須遵守以下條款：*

I ACKNOWLEDGE HAVING READ, UNDERSTOOD AND AGREED to the Release of liability, Waiver of all possible claims, Assumption of risks, and Service consent for myself and every participant in my family/group joining me to the chosen venue as indicated in this form.本人確認已閱讀、理解並同意上述的《免責、放棄任何索償、風險承擔聲明及服務同意書》，以及對本人及攜同的每位參加者的風險承擔。
Consent 同意 -- I agree to be contacted by e-mail and phone call 我同意工作人員將會通過電郵及電話聯繫我。*

Agree 同意Please contact me by E-mail ONLY 我同意工作人員只通過電郵聯繫我。
I agree to be photographed, video-recorded and voice-recorded during the event for possible future use for CFSO publications, internet, and other print media and electronic media. 本人同意授權予家和在本活動中進行拍攝、錄影及錄音，以及同意授權相片及影像用於其刊物、通訊、及其他印刷媒體、電子媒體及互聯網。*

Agree 同意Disagree 不同意
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Mobile Dental Van Registration Form 免費牙齒護理服務登記表格