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Sharing Smiles - Individual Registration
Thank you for your interest! Program information is here https://empoweringtheages.org/sharing-smiles/

Please complete this form on behalf of yourself, your child, your parent, your grandparent or another loved one. Please complete one form for each person who wants to participate.

Anyone completing this form must be age 18 or over. If you are completing this form on behalf of a child under 18, you must also complete and submit the parent/guardian permission found here: https://www.empoweringtheages.org/documents/

Once you have submitted this form, you will receive an email confirmation with suggestions for your communication and content, along with additional details.

By submitting this form, you consent for us to keep in touch with you via our monthly e-newsletter. You may opt out of the e-newsletter by following the unsubscribe link at the bottom of each newsletter. We will not share your email address. Additionally, as we will be reviewing the content of your emails prior to sending, we will reach out with any concerns to the content.
What is the first and last name of the person completing this form? (You must be age 18+; if you are younger, please ask a parent or guardian to complete it for you.) *
What is the name of the Sharing Smiles participant (the person who will be writing notes)? First name is required, last name is optional.
What age range is the Sharing Smiles participant? *
What is your email address? (This will not be shared with your writing partner.) *
Email or postal mail? Email is preferred, if possible. *
If you requested postal mail, what is your mailing address? (This will not be shared with your writing partner.)
How did you hear about Sharing Smiles? *
Required
Any comments or questions for us so far?
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