Category of Program
     Component or Branch Level
     Individual or Small Group

Name of component/branch OR individual/group submitting entry:
     

Key contact person(s):
     

Phone number(s):
     

Date(s) of program(s):
     

Location:
     

Program goal(s):
     

Program theme (if any):
     

Describe your program:
     

How many ISDS members were involved in planning and implementing your event? (Please list)
     

How did your program impact the public’s dental health education? (please indicate how many participants were reached by your program)
     

Did you recruit any affiliates (e.g., hygienists, assistants, Alliance members, educators, nurses, pharmacists, etc.) to help with your program?
   Yes   No
     If "yes", who was involved?
     

Did you use any Illinois State Dental Society materials in your observance, e.g., Got Rot brochures, Flossie materials/costume?
   Yes   No
     If "yes", how?
     

What did you do this year to ensure some continuity in planning next year’s observance of NCDHM?
     

Additional Notes or List of Supporting Materials to be sent
     

Supporting materials such as photographs, newspaper clippings and other materials may be included with this application form for review by the panel of judges. Such materials may be transmitted electronically to Gloria Pitchford.

Questions? Contact ISDS Communications Assistant Gloria Pitchford at 800/475-4737.