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Thank You For Your Interest in Hosting

A Give Kids A Smile Event In 2019

 

 

 

 

 

 

Registration Form

 











Please be prepared to discuss the items below at the One-On-One meeting you will be having with the GKAS Coordinator.
Total number of volunteers you plan to have on that day per category. This includes your staff participating and any volunteers you obtain yourself we encourage you to contact your colleagues personally. and any you request from TCDS.
Non-Private Offices: Please be prepared to let us know, by category, how many of the volunteers you foresee to have at your main day you need TCDS to TRY to get for you. Example: If you put above that you plan to have 5 dentists volunteering at your main event, and you put 2 next to dentists below, you are telling us that out of the total 5 dentists you need on this day, 2 of those you need TCDS to TRY to find for you. We encourage you to contact your colleagues personally.

Private Offices: If you will need TCDS to TRY to find you some volunteers you will need to fill out the request form which you can find the link to download it at the end of your registration process.
Total number of volunteers you plan to have on your Pre-Screening day per category. This includes your staff participating and any volunteers you obtain yourself and any you request from TCDS.
Non-Private Offices: Please be prepared to let us know, by category, how many of the volunteers you foresee to have at your pre-screening day you need TCDS to TRY to get for you. Example: If you put above that you plan to have 5 dentists volunteering at your pre-screening day, and you put 2 next to dentists below, you are telling us that out of the total 5 dentists you need on this day, 2 of those you need TCDS to TRY to find for you. We encourage you to contact your colleagues personally.

Private Offices: If you will need TCDS to find you some volunteers you will need to fill out the request form which you can find the link to download it at the end of your registration process.
All Free Clinics held under the ADA’s Give Kids A Smile Program are NOT to receive compensation for provided services from patients directly or from any third-party payor (including reimbursement from any insurance policy, health plan, or under any Federal or State health benefits program).
If any kind of compensation is received for provided services, the clinic will be banned from participating in Tri-County’s Give Kids A Smile program.
By signing below, you acknowledge and agree that you have read, understand, and claim that the information listed in this Hosting a Clinic Agreement is true and accurate. If any changes are made to this agreement they need to be requested in writing to the GKAS coordinator at GKAS@tcds.org.