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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
*
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Donate
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Staff
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PROGRAMS
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PHOTO GALLERY
