Enrol your child in the Yukon Children's Dental Program

Start
Child name (DoR)
Consent
Parent or legal guardian information
Child's information
Child's medical and dental information
Finish and submit

Start
Consent
Parent or legal guardian information
Child's information
Child's medical and dental information
Finish and submit

Start
Child name (DoR)
Consent
Parent or legal guardian information
Child's information
Child's medical and dental information
Finish and submit

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Use this form to enrol your child in the Yukon Children's Dental Program. If you do not want to enrol your child in the program, you can still use this form to provide consent for limited information sharing between the Department of Education and the Department of Health and Social Services.

This information sharing does not include your child’s medical or dental information.

Providing consent for information sharing is optional.

Average time to complete: 10 minutes 
Application fee: There is no fee.

Before you start

You need a MyYukon account to use the online form.
You will also need:
- your phone number;
- your email address; and
- information about your child(ren).

You must complete a separate form for each child.

Other ways to provide consent

Find more details, instructions and other ways to access this service on Yukon.ca.

A note about privacy

Information contained in this form is collected, used, and disclosed in accordance with Yukon’s Health Information Privacy and Management Act (HIPMA) and other applicable laws. A written statement of Health and Social Services information practices can be viewed on yukon.ca.

For more details about how we collect, use and disclose personal information contact:

Health and Social Services' Privacy Officer
Email: healthprivacy@yukon.ca
Phone: 867-456-3953, toll free 1-800-661-0408 extension 3953.

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Consent

Consent for child to be enrolled in the Yukon Children's Dental Program

A parent or legal guardian must provide their consent for the child to be enrolled in the Yukon Children's Dental Program. This means the child will have access to an examination and preventative services. After the dental screening or examination, if your child needs restorative treatment, such as fillings, extractions or silver diamine fluoride (SDF), we will send you a separate Consent for Treatment form to review and sign before treatment is provided.

I do not consent to my child being enrolled in the Yukon Children’s Dental Program. We’ll take our child to our family dentist or use our private insurance or other coverage.

I consent to my child’s enrolment in the Yukon Children’s Dental Program and the services indicated below that are provided by program staff.

As part of the examination, the services listed below may be provided by dental program staff.

YOU MUST INDICATE THE SERVICE(S) YOU CONSENT TO YOUR CHILD RECEIVING:

X-rays

Fluoride varnish

Sealants

Cleaning of teeth - only provided based on the need assessed by the clinician and time available during the school year.

As most of the products used in this program contain small amounts of fluoride, declining fluoride varnish may also mean declining similar treatment services offered through the program.

Consent for information sharing between Health and Social Services and Education

To help the Yukon Children’s Dental Program plan and deliver services effectively in schools, the Department of Health and Social Services is asking for your one-time consent for the Department of Education to share your child’s basic information, including their name, date of birth, parent or guardian contact information, school, grade, class and teacher. This information helps dental program staff plan services based on the needs of each school and its classes.

If you agree to enrol your child in the Yukon Children’s Dental Program and receive services, you are also agreeing to the sharing of this basic information between the Department of Education and the Department of Health and Social Services for program delivery purposes.

Parents and legal guardians can revoke this consent at any time.

This consent does not give permission for any health services.

I understand and agree.

I do not agree. Not agreeing may limit our ability to provide services in the school dental clinic and to communicate important Yukon Children’s Dental Program information.

You have chosen not to consent to the enrolment of your child in the Yukon Children's Dental Program or to information sharing between Health and Social Services and Education. You must provide your and your child's basic information and select "Finish and submit" to confirm your choice.

Parent

First name

Last name

We will send a copy of this completed form to this email address.

Child

First name

Last name

Date of birth

School currently attending

Select the name of the school your child is currently attending.

Grade

This is the grade your child is currently in.

Signature

Full name

Date

Form type

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Parent or legal guardian information

Primary parent or legal guardian

First name

Last name

Phone

This is your primary phone number.

We will send a copy of this completed form to this email address.

Mailing address

Address line 1

Enter the primary delivery information, such as street number and name; PO box; or rural route identifier. Enter GD for General Delivery.

Address line 2 (optional)

Enter additional details, such as the unit, apartment or suite; station information; or site and compartment information.

City, town or village

Territory or province

Postal code

Postal code format: Y1A 3J9 or Y0B 1N0.

Secondary parent or legal guardian

First name

Last name

Phone

This is the primary phone number of the secondary parent or legal guardian.

We will send a copy of this completed form to this email address.

Mailing address

Same as primary parent or legal guardian

Address line 1

Enter the primary delivery information, such as street number and name; PO box; or rural route identifier. Enter GD for General Delivery.

Address line 2 (optional)

Enter additional details, such as the unit, apartment or suite; station information; or site and compartment information.

City, town or village

Territory or province

Postal code

Postal code format: Y1A 3J9 or Y0B 1N0.

Address line 1

Address line 2 (optional)

City, town or village

Territory or province

Postal code

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Child's information

First name

Last name

Date of birth

Gender

Female

Male

Non-binary

Other

Select the option that best describes your child's gender.

Other

Child's school information

School currently attending

Select the name of the school your child is currently attending.

Grade

This is the grade your child is currently in.

Has this child previously attended another school in the Yukon?

Yes

Last school your child attended

This is the name of the school your child last attended in the Yukon.

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Child's medical and dental information

The Yukon Children's Dental Program provides services to children in a variety of age ranges. Some of the questions below may not apply to your child's age, but you still need to answer them.

Child's medical information

Is your child currently under a doctor’s care for an illness or medical condition?

Yes

Reason for care

Describe all illnesses or medical conditions a doctor is treating your child for.

Is your child currently taking any medications?

Yes

Medications your child is currently taking

List all medications your child is taking. Include all over-the-counter and prescription medications.

Has your child ever been hospitalized?

Yes

Hospitalization(s)

List instances when your child was hospitalized. Include the date, length of stay and reason for hospital stay.

Has your child’s doctor advised that they require antibiotics before surgery or dental treatment?

Yes

What medical conditions has your child had in the past?

Abnormal bleeding

Allergies (For example: bee stings, dairy, food, latex, medication, silver, etc.)

Asthma

Cancer (For example, leukemia)

Communicable disease (For example: HIV infection, sexually transmitted infection (STI), tuberculosis, etc.)

Diabetes

Epilepsy

Heart disease

Heart murmur

High blood pressure

Kidney disease

Liver disease

Reaction to dental treatment

Rheumatic fever

Thyroid disease

Other

Select all medical conditions your child has had in the past.

Medical condition details

Use the space to provide details or explain any of the medical condition you selected in the previous question. If your child has, or is being investigated for a condition or disease not listed above, include your explanations in the same space.

Is your child allergic to silver?

Yes

If applicable, does your child smoke or use tobacco-related products?

Yes

If applicable, is your child pregnant?

Yes

Are there any reasons why your child might have difficulty undergoing dental services?

Yes

This can include medical or mental health reasons.

Reasons your child may have difficulties with dental services

Child's dental information

Has your child been enrolled in the Yukon Children's Dental Program before?

Yes

Unsure

Does your child brush their teeth 2 or more times a day?

Yes

Does your child floss their teeth every day?

Yes

Additional notes about your child's dental treatment (optional)

Include any additional details you think are important for our staff to know regarding your child's dental treatment.

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Review your application details before submitting

This form is not complete until you click the "Finish and submit" button below.

Consent

Consent for child to be enrolled in the Yukon Children's Dental Program

I do not consent to my child being enrolled in the Yukon Children’s Dental Program. We’ll take our child to our family dentist or use our private insurance or other coverage.

I consent to my child’s enrolment in the Yukon Children’s Dental Program and the services indicated below that are provided by program staff.

X-rays

Fluoride varnish

Sealants

Cleaning of teeth - only provided based on the need assessed by the clinician and time available during the school year.

Consent for information sharing between Health and Social Services and Education

To provide dental services efficiently to your child in a school clinic setting, the Department of Education may share your child’s basic information with the Yukon Children’s Dental Program (YCDP), which is administered by the Department of Health and Social Services.

This information helps dental program staff identify your child at school and coordinate clinic visits. It may include details such as your child’s name, school, grade, classroom and teacher.

If you agree to enroll your child in the Yukon Children’s Dental Program and receive services, you are also agreeing to the sharing of this basic information between the Department of Education and the Department of Health and Social Services for program delivery purposes.

Parents and legal guardians can revoke this consent at any time.

This consent does not give permission for any health services.

I understand and agree.

I do not agree. Not agreeing may limit our ability to provide services in the school dental clinic and to communicate important Yukon Children’s Dental Program information.

Parent or legal guardian information

Primary parent or legal guardian

First name

Last name

Phone

Address line 1

Address line 2 (optional)

City, town or village

Territory or province

Postal code

Secondary parent or legal guardian

First name

Last name

Phone

Address line 1

Address line 2 (optional)

City, town or village

Territory or province

Postal code

Child's information

First name

Last name

Date of birth

Gender

Child's school information

School currently attending

Grade

Has this child previously attended another school in the Yukon?

Yes

Last school your child attended

Child's medical and dental information

Child's medical information

Is your child currently under a doctor’s care for an illness or medical condition?

Yes

Reason for care

Is your child currently taking any medications?

Yes

Medications your child is currently taking

Has your child ever been hospitalized?

Yes

Hospitalization(s)

Has your child’s doctor advised that they require antibiotics before surgery or dental treatment?

Yes

What medical conditions has your child had in the past?

Abnormal bleeding

Allergies (For example: bee stings, dairy, food, latex, medication, silver, etc.)

Asthma

Cancer (For example, leukemia)

Communicable disease (For example: HIV infection, sexually transmitted infection (STI), tuberculosis, etc.)

Diabetes

Epilepsy

Heart disease

Heart murmur

High blood pressure

Kidney disease

Liver disease

Reaction to dental treatment

Rheumatic fever

Thyroid disease

Other

Medical condition details

Is your child allergic to silver?

Yes

Does your child smoke or use tobacco-related products?

Yes

Is your child pregnant?

Yes

Are there any reasons why your child might have difficulty undergoing dental services?

Yes

Reasons your child may have difficulties with dental services

Child's dental information

Has your child been enrolled in the Yukon Children's Dental Program before?

Yes

Unsure

Does your child brush their teeth 2 or more times a day?

Yes

Does your child floss their teeth every day?

Yes

Additional notes about your child's dental treatment (optional)

submission title SPO