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BRINGING BRIGHT SMILES TO THE BLUEGRASS
Signup for Mobile Dental Clinic @ Keeneland

* Indicates required field

Farm Contact *

First

Last

Farm name *

Phone Number *

Email *

Please provide name of Farm Worker #1. *

Will a family member(s) be attending? *

spouse child 1 child 2

Best Time for Appointment *

Morning (10 a.m. to noon) Early Afternoon (noon to 3 p.m.) Late Afternoon (3 to 5 p.m.)

Appointment Date *

May 24 May 25 May 26

Please provide name of Farm Worker #2. *

Will a family member(s) be attending? *

Spouse child 1 child 2

Best time for appointment *

Morning (10 a.m. to noon) Early afternoon (noon to 3 p.m.) Late afternoon (3 p.m. to 5 p.m.)

Appointment Date *

May 24 May 25 May 26

Please provide name of Farm Worker #3. *

Will a family member(s) be attending? *

Spouse child 1 child 2

Best time for appointment *

Morning (10 a.m. to noon) Early afternoon (noon to 3 p.m.) Late afternoon (3 p.m. to 5 p.m.)

Appointment Date *

May 24 May 25 May 26

Please provide name of Farm Worker #4 *

Will a family member(s) be attending? *

Spouse child 1 child 2

Best time for appointment *

Morning (10 a.m. to noon) Early afternoon (noon to 3 p.m.) Late afternoon (3 p.m. to 5 p.m.)

Appointment date *

May 24 May 25 May 26

Please provide name of Farm Worker #5. *

Will a family member(s) be attending? *

Spouse child 1 child 2

Best time for Appointment *

Morning (10 a.m. to noon) Early afternoon (noon to 3 p.m.) Late afternoon (3 p.m. to 5 p.m.)

Appointment Date *

May 24 May 25 May 26

If your farm provides dental insurance, please list insurance company *

Comment *

Submit

Copyright Blue Grass Farms Charities, 2025
Mailing Address: P.O. Box 12252, Lexington, KY 40582
(859) 219-0910
[email protected]

Home
About Us
Get Help
Give Back
Contact Us

BRINGING BRIGHT SMILES ​ TO THE BLUEGRASSSignup for Mobile Dental Clinic @ Keeneland

BRINGING BRIGHT SMILES TO THE BLUEGRASS
Signup for Mobile Dental Clinic @ Keeneland