Give Kids A Smile Day
Reporting Form

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:

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, or by postal mail (see below).

All entries must be submitted by April 11.

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


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