Van Visit Sign Up: Colgate Bright Smiles Bright Futures

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Thank you for your interest in scheduling a Van Visit with the Colgate Bright Smiles Bright Futures Chicago Team! Please complete the following information so we can best accommodate your site.

Our mobile dental van program has limited travel during this time, so we may or may not be able to visit your site in-person and provide education and free dental screenings, however another offering is a "Virtual Van Visit" in which we present and demonstrate oral health education to children 12 and under in a virtual setting. The sessions are about 20-30 minutes long. So far, the kids, families, and teachers have been enjoying the information and FREE Colgate oral care kits!

We look forward to providing a Van Visit, whether on-site or virtual, to the children you serve.
Thank you for your time,
Colgate Bright Smiles Bright Futures, Chicago Team

Name of Site *

First & Last Name of Site Contact Person *

Title/Position of Site Contact Person *

Preferred Email Address *

Preferred Phone Number *

Site Address Line 1 *

Site Address Line 2

City *

State *

Zip Code *

Approximately how many children aged 12 and under do you reach? And what is the exact age range of the kids you serve? (Ex. 20 kids, aged 3-5) *

Which virtual platform(s) is your site most comfortable with? If you would like an in-person van visit, please select that option. *

Zoom

Google Meet

Google Classroom

We have not used virtual platforms yet, but are willing to try!

In-Person Visit

Other:

Required

Please provide upcoming dates & times that work best for your site to schedule a Van Visit (whether virtual or on-site).

If applicable, please list any other sites or partners that you believe may also be interested in scheduling a Virtual Van Visit for the children they serve. Please also add a contact person and/or contact info. Thank you!

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