Category of Program
     Component or Branch Level
     Dental Office or Small Group

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

Key contact person(s) & Address:
     

Phone number(s):
     

Location of event:
     

Did any other group(s) co-sponsor the event?
    Yes    No
     If "yes", name of co-sponsor(s)?
     

Number of children receiving care:     

Number of dentists participating:     

Did any politicians attend?
    Yes    No
     If "yes", whom?
     

What type of local media coverage did your event receive:
     

Briefly describe your program:
     

This information is provided by:
     

Photographs may be included with your submission. Such materials may be transmitted by e-mail to lbeane@isds.org, or by postal mail (see below).

All entries must be submitted by March 16.

Return to:
Attn: Lee Ann Beane
IL State Dental Society
P O Box 376
Springfield, IL 62705
Fax: 217/525-8872

Type in the code below. It is case sensitive.