Dentist Registration

Dentist Registration Form
*Dentist Name:
Contact Name (if other than dentist):
*Work Phone:
	(Your work phone number will be displayed on the Brushamania website.)
Home Phone:
Fax:
*Email:
	(Email is the best way to communicate with everyone involved. If you do not have your own email address, please provide us with a friend's address so that we may send you the necessary updates.)
*Number of schools you wish to attend:
	(You may attend other schools during the month of April.)
	I would like to help out on the following committees:
Organizing Committee:	Oversee event organization
Loot Bag Committee:	Collect contents of loot bags, assemble and distribute to schools
PR/Media Committee:	Prepare News Releases Invite media to event Invite politicians and guests; Arrange interviews Arrange Public Service Announcements Promote Brush-a-mania throughout Ontario. (Place posters in libraries, rec centres, etc.)
Sponsor Committee:	Contact Sponsors for money, prizes, product or services.
Telephoning Committee:	Recruit/follow-up with schools, dentists, Rotarians.
	For more information, contact Raffy Chouljian: raffy@brushamania.ca

	* shows the required fields.