Smile Check School Sign-Up
Name of School / Organization / Facility:
*
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Contact Person for Program Coordination:
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
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Person Authorized to Approve Participation with Program (e.g. Superintendent, Director, CEO, Owner):
Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
Acknowledgement:
Completing this form authorizes a dental professional from the Bureau of Oral Health and Dental Services to reach out to your designated contact to discuss program options and schedule an event at your location.
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