The Children’s Oral Health Institute

Tel: 866.508.7400
Fax: 410.356.8574

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Lessons In A Lunch Box:
Healthy Teeth Essentials & Facts About Snacks®

Program Registration Form

Dental School/Organization Information
Name
Address
City
State
Zip Code
Office Phone
Dean/ Chairperson
Website
Contact Names
Contact Names
Contact Emails
Contact Emails
Contact Phone numbers
Contact Phone numbers
Dental Students #
Anticipated Event Date
Anticipated Event Time
FedEx or UPS Acct #	FedEx UPS
Elementary School Information
Elementary School Name
Elementary School Address
City
State
Zip Code
Office Phone
Principal
Website
Contact Names
Contact Names
Contact Emails
Contact Emails
Contact Phone numbers
Contact Phone numbers
Number of Students in grades 2 and/or 3