Portable SMILE Express Location Contact Form

PORTABLE SMILE EXPRESS LOCATION CONTACT FORM

Thank you for filling this form completely for each visit. We look forward to visiting your location in the near future. The questionnaire is designed for portable school-based services, so if a field does not apply, please type "N/A".

* Indicates required field

What county is your location in? *

Name of Principal or Administrator *

School/location name *

Name of person filling out form *

Contact person (person we will speak directly to during visit) *

When will Smile Express visit your location (date)? *

Contact Person Phone Number *

Contact Person Email *

Time school starts and ends (ex. 7:00am - 3:05pm) *

Time first bus leaves at end of day *

Where would you like us to set up our portable clinic? (a 10'x15' space minumum required) *

Time lunches begin and end *

What is the earliest time we can arrive to begin setting up? *

Is there access to power and water? *

Address of exact visit location (good for GPS search) *

Line 1

Line 2

City

State

Zip Code

Country

Would someone be available to assist us in bringing in and taking out our mobile equipment? *

If your location has limited cellular service, please provide Wi-Fi and password information (this will only be used for student-related business while at your school). Please list any information you think would be helpful to our program (best route of entry, things to watch for, special requests, etc.) *

Submit