* 1. To find out if your town is available, & receive more information please fill out the following:

* 2. Why do you feel you are a good candidate to lead your town in Kids Day America/International?

* 3. What Chiropractic College did you graduate from?

* 4. What year did you graduate from Chiropractic College?

* 5. Enter the best day & time during the next week for you to receive a call (two options please). All calls based on Eastern Standard Time (NYC)

Date / Time
Date / Time