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Share A Smile 2024 Volunteer Form
Giving kids an even bigger reason to smile! "Share A Smile" is an extension of the Give Kids A Smile (GKAS) program. The goal is to open up access to care for children who are uninsured or under insured. Thank you for your generosity and commitment to our local communities!
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What is your full name and title?
Your answer
In what county do you serve?
Your answer
What is the best email to reach you?
Your answer
What is the name of your practice?
Your answer
What is your office's street address?
Your answer
What town is your office located?
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Your answer
What is the office zip code?
*
Your answer
What is your office phone number?
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Your answer
How many children can you commit to treating?
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Your answer
Are you willing to treat patients with special healthcare needs?
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Yes
No
If so, what types of patients can you accommodate? (ASD, physical impairment, wheelchair, etc)
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Your answer
Any specific preferences (patient's age, time of day, sedation modalities, etc.)
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Your answer
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