NDA Health Now® Community Event Request Form

Event Name

Date

Time

Event Location

City

State/Province

Zip/Postal

Event Coordinator Contact Name

Phone

Mobile

Email

On-site Contact Name

On-site Contact Phone

Number of Anticipated Participants

Age Range

Estimated Number of Attendees

%Children

%Adults

%Seniors

Will There Be Security?

Yes

No

Do Our Volunteers Need ID Badges?

Yes

No

Is there a Specific Area for Volunteer Registration?

Yes

No

Where is this Volunteer Registration Area Located?

Will Our Volunteers Have Assigned Parking?

Yes

No

Can We Have Information Tables Inside?

Yes

No

Can We Have Information Tables Outside?

Yes

No

Are There Banner/Sign Restrictions (i.e. size, location)?

Yes

No

Please Explain the Banner/Sign Restrictions

Are you requesting program materials for this event? If so, which ones?

Razzle Dazzle Smiles for Life™ - Two part program for seniors and caregivers

“Mouth-Body Link™” - Adult education presentations (English)

“Mouth-Body Link™” - Adult education presentations (Spanish)

We DO NOT require program materials for this event

Are you requesting audio/visual materials for this event? If so, which ones?

Links to Healthy Smiles

Dr. Rabbit and the Tooth Defenders

Dr. Rabbit and the Legend of Tooth Kingdom

We DO NOT require audio/visual materials for this event

How many Pamphlets/Brochures are you requesting?

How many Donated Dental Products (toothbrushes, toothpaste, etc.) are you requesting?

Shipping Address

City

State/Province

Zip/Postal

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