Nomination Submission Form
DeVaney Dentistry is excited to host our first annual Operation Christmas Smile this holiday season! We will be selecting two families to provide them with free dental care. If you know a family having hardship, or down on their luck, with no dental insurance and in need of dental treatment, please complete this form for our consideration.
Your name *
Your answer
Your email address *
Your answer
Your phone number *
Your answer
Nominated Family’s Name *
Your answer
Nominated Family's Phone Number *
Your answer
Relationship to Nominated Family *
Your answer
Please provide as much information about nominated family as you can (number of members in their family and ages if known, reason for nominating, etc.). *
Your answer
How did you hear about this event?
We will be closing nominations on December 15 to begin our making our selections. Thanks for your help in helping our community!
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