DELAWARE STATE DENTAL SOCIETY
13^TH ANNUAL GIVE KIDS A SMILE
VOLUNTEER REGISTRATION

Registration Category *

Friday, February 5, 2015
    Delaware Technical Community College
    Dental Health Center
    333 Shipley Street, Wilmington. DE
    8:00 AM to 2:30 PM

Saturday, February 6, 2015
    Norman S. Steward, Jr., DDS
    214 S. Walnut Street, Milford, DE
    8:00 AM to 2:30 PM

Yes, I can remain beyond 2:30 PM if necessary for restorative procedures.

Yes, I can act as a Spanish Interpreter.

Yes, I am willing to provide a monetary contribution towards dental supplies and/or
refreshments for the volunteers. Please send a check to the DSDS office. Thank you.

First Name *

Last Name *

Addresss

City

State

Zip

Office Phone

Cell Phone

Fax

Email *

DELAWARE STATE DENTAL SOCIETY 13TH ANNUAL GIVE KIDS A SMILE VOLUNTEER REGISTRATION

DELAWARE STATE DENTAL SOCIETY
13^TH ANNUAL GIVE KIDS A SMILE
VOLUNTEER REGISTRATION