Smiles 4 Miles registration form 2016

Please complete this form to register to participate in Smiles 4 Miles, and to receive toothbrushes and toothpaste.

Please ensure the information provided is accurate and all the relevant sections are completed before you submit this form.
Name of early childhood service:
Street Address:
Postcode:
Phone:
Shire/Council:
Your name:
Your role in the early childhood service (e.g. educator):
Email:
Please tick the type of early childhood service
Number of children who will be participating in Smiles 4
Miles this year
Please select the most appropriate box.
Please note resources can only be provided for children who are participating in Smiles 4 Miles.
______ Number of children
Indicate which kindergarten group/s are participating
3 year old group
4 year old group
_______ Number of children
Indicate which group/s are participating
3 year old group
4 year old group
Kindergarten/Preschool
Long Day Care with a Kindergarten Program
Long Day Care (without a kindergarten program)
_______ Number of children
Family Day Care
_______
Number of children
Play Group
_______
Number of children
Other, please specify ________________________
_______
Number of children
Are you participating in the Healthy Together Victoria
Achievement Program?
Yes
No
Does your service have children or families who identify as
Aboriginal or Torres Strait Islander?
Yes
No
Is your service an Aboriginal early childhood service?
Yes
No
Your Smiles 4 Miles coordinator will advise you on expected delivery times once you have completed this form.
By completing and signing this form, I agree to participate in the Smiles 4 Miles program and will work towards
achieving or maintaining the Smiles 4 Miles award in 2015.
Manager signature: ________________________________________ Manager name:__________________________
Please send this form back to: Jaimie Poorter via [email protected] or Locked Bag 1 Seymour, Vic 3661
This form is to be returned by: Monday 16 November 2016
Smiles 4 Miles coordinator use only (must be completed)
Number of resources to be ordered for this service:
___toothbrushes
___ toothpaste
DHSV office use only
Date registration form was received:
Date resource order was processed:
Smiles 4 Miles is an initiative of Dental Health Services Victoria, working in
partnership with local organisations to improve the oral health of the youngest
children in our community.