SMILE Express Location Contact Form

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. It is our goal to be out of the way as much as possible, but we are a very large vehicle. Our mobile dental clinic is 38' long and has slides (bump-outs) on both sides. The minimum area that we can fit comfortably into is 50' x 20', depending upon entry and exit into parking spot.

* Indicates required field

School/location name *

Name of school Principal *

Name of person filling out form *

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

When will Smile Express visit your school (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 in your building would you like us to set up our education table? *

Time lunches begin and end *

What is the window of time we can arrive and setup in our parking spot? (before buses arrive is ideal) *

Is there access to a 50amp plug near parking spot (within 25ft)? *

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

Line 1

Line 2

City

State

Zip Code

Country

Will there be a dedicated parent volunteer or other person to run students back and forth from school to our mobile unit (strongly encouraged and appreciated)? *

Yes No Maybe

Please list any information you think would be helpful to our program (best route of entry, things to watch for, special requests, etc.) *

Submit