Contact Information
Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Shipping Address
(Where you would like the books and toothbrush kits sent)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Troop Information
Council
*
Please Select
Girl Scouts of Silver Sage
Troop Number
*
What day did your troop complete the Smile Squad Girl Scout Patch Curriculum?
*
-
Month
-
Day
Year
Date
Indicate the number of scouts who earned the patch:
Daisies:
Brownies:
Juniors:
Cadettes:
Seniors/Ambassadors:
Total Number of Girls:
Additional Information and Feedback
How did you hear about our Smile Squad Patch Program?
Please Select
Search Engine
Delta Dental Website
Friend or Family Member
Girl Scout Staff
Girl Scout Program Guide
Social Media
Other (Please List)
Other:
Please select what activities your troop completed from the category in the drop down menus below
Discover:
*
Please Select
Interview with a dental professional or student
Try fun oral health science activities
Watch a cool video
Examine the inside of your mouth
Connect:
*
Please Select
Track 2 x 2 + 20
Record what you drink for one week
Identify healthy vs. unhealthy food and drinks
Research tooth culture
Take Action:
*
Please Select
Produce a video or write a song
Read an oral health storybook
Collect and donate
Make water cool
How satisfied were you with the educational component related to this patch?
*
Please Select
Very Satisfied
Satisfied
Somewhat Satisfied
Not Satisfied
How valuable do you think this information is in your scouts’ lives?
*
Please Select
Very Valuable
Somewhat Valuable
Not Valuable
What activity from the curriculum was the most meaningful for your troop?
How did your scouts' behaviors change since earning this patch? (Check all that apply)
*
Brushing teeth more
Making healthy food choices
Drinking more water
Reading more
Other (please list)
Other:
Do you have any additional feedback to share?
Submit
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