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Give Kids A Smile® 2014 - Local project profile

Since February 2003 when the Wisconsin Dental Association joined the American Dental Association in launching Give Kids A Smile®, Wisconsin dentists, dental team members, dental and hygiene students and community advocates have provided $7.2 million in care to more than 50,000 low-income children as part of the national access to care day and throughout National Children's Dental Health Month.

Register your event with the WDA and ADA to be eligible for FREE event resources including dental products, stickers, posters and pediatric dental records.

Sign-up with the ADA by Nov. 8, 2013 to be considered for dental products provided by Colgate and Henry Schein Dental.

Register with the WDA by Jan. 10, 2014 to be included in statewide and regional WDA press releases and eligible for other exclusive offers. Press releases are sent out to local print, radio, TV and online media contacts.

New in 2014! All Wisconsin GKAS® events registered with the WDA and the ADA will be entered in a drawing to win one of four cases of toothbrushes and toothpaste. Thank you to the WDA Foundation and its Smile Grant Program for providing these oral hygiene prizes.

Do you receive the GKAS® e-Update newsletter? Each issue has valuable information for planning your event and deadline reminders. Click here or visit the GKAS® Dental Professionals section on WDA.org to sign-up.

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* 1. Dental practice name

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* 2. Office address

Address 1:

Address 2:

City/town:

State:

Zip:

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* 3. Contact information

Contact name:

Office phone:

Contact email:

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* 4. WDA member name(s)
*please list all participating dentists and hygienists

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* 5. Are you holiding a pre-screening event?

Yes

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* 6. What is the date of pre-sceening event?

Date:

Date

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* 7. What time does the pre-screening event start?

Start time:

Time

AM/PM

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* 8. What time does the pre-screening event end?

End time:

Time

AM/PM

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* 9. Where will pre-screening event be held?

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* 10. Project/treatment date(s)

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* 11. Project/treatment location(s)

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* 12. Please indicate the following:

# participating dentists

# particiapting dental hygienists

# other team support

# of projected patients

Patients(s) approximate age(s)

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* 13. Are you participating in GKAS® with any partner organizations?

Boys and Girls Clubs

Community charitable dental and/or medical clinics

Faith-based groups

Head Start centers

Social service agencies

United Way chapters

School district(s)

Local health departments

Other (please specify)

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* 14. Are you working in conjunction with a dental component/society?

Yes

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* 15. If you are working in conjunction with a local dental society, which one?

	Local dental societies
Select one:	Select one: Local dental societies menu

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* 16. How are you participating in GKAS®?

Visiting school classrooms with oral hygiene presentations

Providing sealants and/or fluoride rinse/varnish

Conducting dental screenings

Performing selected endodontic and surgical services

Other (please specify)

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* 17. Any details to share with local media and WDA Journal readers?

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* 18. Are you scheduling appointments or holding a walk-in event?

Scheduling appointments

Holding a walk-in event

Both

Other (please specify)

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* 19. If we get a call from the public or an organization wanting to refer a child or children in your area to a GKAS® event, may we refer them to your program?

Yes

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* 20. Estimated value of services you expect to deliver:

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* 21. Do you plan to invite your (local, state or national) elected officials to your GKAS® event?

Yes

Not sure

We're interested in doing this, but would like more information. Please have someone from the WDA contact us at (list name, email and phone number):

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* 22. If you answered "yes" to the previous item, please name your elected officials:

Name

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* 23. What WDA tools will you utilize?

Customizable legislator invite

Customizable legislator letter

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* 1. Dental practice name

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* 2. Office address

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* 3. Contact information

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* 4. WDA member name(s)*please list all participating dentists and hygienists

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* 5. Are you holiding a pre-screening event?

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* 6. What is the date of pre-sceening event?

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* 7. What time does the pre-screening event start?

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* 8. What time does the pre-screening event end?

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* 9. Where will pre-screening event be held?

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* 10. Project/treatment date(s)

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* 11. Project/treatment location(s)

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* 12. Please indicate the following:

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* 13. Are you participating in GKAS® with any partner organizations?

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* 14. Are you working in conjunction with a dental component/society?

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* 15. If you are working in conjunction with a local dental society, which one?

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* 16. How are you participating in GKAS®?

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* 17. Any details to share with local media and WDA Journal readers?

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* 18. Are you scheduling appointments or holding a walk-in event?

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* 19. If we get a call from the public or an organization wanting to refer a child or children in your area to a GKAS® event, may we refer them to your program?

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* 20. Estimated value of services you expect to deliver:

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* 21. Do you plan to invite your (local, state or national) elected officials to your GKAS® event?

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* 22. If you answered "yes" to the previous item, please name your elected officials:

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* 23. What WDA tools will you utilize?

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* 24. What additional resources can the WDA make available to help you with your event?

* 4. WDA member name(s)
*please list all participating dentists and hygienists