National Children's Dental Health Month
Reporting Form

All entries must be received by April 11.

Required fields are red

Congratulations on a successful NCDHM observance! Please complete all sections of the form below.

Category of Program

     Component or Branch Level
     Individual or Small Group

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


Key contact person(s) & Address:


Phone number(s):


Date(s) of program(s):




Program goal(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?


Additional Comments


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Photographs may be included with your reporting form. Send to Gloria Pitchford.