Congratulations on an outstanding Give Kids A Smile event! Please complete ALL sections of the form below.
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:
Location of event:
Did any other group(s) co-sponsor the event?
If "yes", name of co-sponsor(s)?
Number of children receiving care:
Number of dentists participating:
Did any politicians attend?
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 firstname.lastname@example.org, or by postal mail (see below).
All entries must be submitted by April 11.
Attn: Lee Ann Beane
IL State Dental Society
P O Box 376
Springfield, IL 62705
Type in the code below. It is case sensitive.
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Illinois State Dental Society • P.O. Box 376 • Springfield, IL 62705 • (217) 525-1406
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