Congratulations on a successful NCDHM observance! Please complete all sections of the form below.
Category of Program
Name of component/branch OR individual/group submitting entry:
Key contact person(s) & Address:
Date(s) of program(s):
Program theme (if any):
Describe your program: (include number of volunteers and participants)
How did your program impact the public's dental health education?
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Photographs may be included with your reporting form. Send to Gloria Pitchford.
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Illinois State Dental Society • P.O. Box 376 • Springfield, IL 62705 • (217) 525-1406
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