Community Engagement Program
Apply for a dentist to visit your company/institution
Your Details
Name
*
First Name
Last Name
Contact Number
*
-
Area Code
Email
*
Tell us about your company/institution
Name
*
Address
*
Street Address
Street Address Line 2
City
State
Postal Code
Are you a:
*
Daycare
Kindergarten
Primary School
High School
Sporting Club
Community Group
Mothers/Parents Group
Aged Care Facility
Other
Other
*
Please advise if parents will be present for the presentation:
Tell us more information about your audience. (e.g. 5-year-olds, teenagers etc.)
*
Approximately how many people will be in attendance?
*
Do any of the participants have any special needs or circumstances that we should consider when preparing the presentation?
*
Do you have a proposed date for the visit? (Please ensure you give a minimum of 4 weeks’ notice)
*
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Month
-
Day
Year
What time you would like the visit?
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
How long would you like the information session to run?
*
Do you have any specific topics that you would like discussed?
*
Please let us know which facilities/equipment you will be able to provide for this presentation. (i.e. room, chairs, computer, projector, WiFi, internet)
*
Submit
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