Give Kids a Smile Day Registration - English
Please answer the questions below to the best of your ability. Each child must have a SEPARATE form filled out. Thank you!
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Child's Name? *
Child's Age? *
Any specific dental needs?  *
Required
Guardian's Name *
Relationship to Child *
Guardian's Phone Number   *
Guardian's Email *
Are any special accommodations or translators needed? (special care, language translator, etc.) If none, then write "NO". *
What time do you prefer to come on the morning of the free clinic? *
Where did you hear about "Give Kids a Smile Day"? *
Required
If you clicked on "Community Organization" in the previous question, which one? If not applicable, do not respond. 
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