National Children's Dental Health Month
Fighting for Good Oral Health "2MIN2X"
Reporting Form

All entries must be received by April 11, 2014.


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):

     



Location:

     



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.



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