Smiles Change Lives and White Brown Smiles event
Parent / Guardian Name
*
First
Last
Child's Name
*
First
Last
Child's Age
*
0 to 6 years old
7 to 21 years old
22 years old or older
Email
*
Mobile Phone
*
How did you learn about the event
*
Flyer (school, church, organization, etc.)
Facebook
Google Ad
A friend told me
my general dentist
newspaper article
TV/Radio
SCL newsletter
Other
Please explain
What is your household size (# of dependents)?
*
2
3
4
5
6
7 or more
What is your household taxable income?
*
$40,599 or less
$40,600 - $51,049
$51,050 - $61,499
$61,500 - $71,949
$71,950 - $82,399
more than $82,400
Comments / Questions
