StarSmilez® - Participation Request

PARTICIPATION REQUEST FORM

StarSmilez® supports the education and practice of great oral health! We partner with health organizations, educational institutes, and private practices to expand the reach of children's oral health messages around the world. StarSmilez® has participated in a variety of programs and events such as Give Kids a Smile, Fall for Smiles and community outreach efforts. If you wish to become a StarSmilez® Partner in promoting children's oral health or to request StarSmilez® participation in an upcoming event or program, please fill out the following information:

Type of Organization: Organization:

Contact Name: Contact Title/Position:

Address Line 1: City:

State: Zipe Code:

Account Email: Phone:

Event Name: Date of Event:

Location of Event(s): Year Event Established:

Event Sponsors: Other Organizations
Supporting Event:

Esitmated number of Participants: Target Audience Program Staff

Primary Message
of Event(s):

**Please include an en executive summary of the event or organization with your request: email to smilecare@starsmilez.com

Type of Organization:		Organization:
Contact Name:		Contact Title/Position:
Address Line 1:		City:
State:		Zipe Code:
Account Email:		Phone:
Event Name:		Date of Event:
Location of Event(s):		Year Event Established:
Event Sponsors:		Other Organizations Supporting Event:
Esitmated number of Participants: Target Audience Program Staff
Primary Message of Event(s):
**Please include an en executive summary of the event or organization with your request: email to smilecare@starsmilez.com