Community Outreach Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

VCU Dental Care provides oral health presentations to organizations, corporations,
schools, and assisted or independent living facilities holding events, workshops or
health fairs. To request a presentation or submit a community event that you
would like VCU Dental Care or VCU School of Dentistry students to participate
in, please complete the following form:

Email *

Event *

Address *

Phone Number *

Type of Event Coverage Request *

OHI - Oral Health Instruction

Corporation Event

Head start or day care program

Elementary School

Middle School

High School

Community Center Activity

Geriatrics, Assistant Living, or Nursing Home Event

VCU School of Dentistry or VCU Dental Care representative to set up a promotional table

Dental Supplies donation (limited quantities)

Speaker Request (please specify below)

Required

Speaker Request:

Please submit request 7-10 business days in advance.

What date would you like to pick-up? (dd/mm/yyyy) *

How many people are you expecting to attend this event?

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Virginia Commonwealth University. Report Abuse

Forms