To enroll in any of our programs, print and complete this form, then mail or fax to us with a $275 deposit.

Registration Form

SMILES FOUNDATION

Name: _____________________________________________________________________

Address: ____________________________________________________________________

City: _______________________________________________________________________

Province/Region: _________________ Postal Code: ___________ Country: ______________

Phone Number: ___________________________ E-mail:_____________________________

Enroll me in the Smiles Foundation Volunteer Program in:

_______ Moca ________ Higuey _______ Puerto Plata _________ PantojaSto Domingo

__________ Santiago ____________ Herrera, Sto Domingo_________ Los Rios, Sto Domingo

Program Start Date: _______________ Program End Date: _______________

Cheque Enclosed ____________________

Billing Address (if different from above):____________________________________________

City: _____________________________________________________________________

Province/Region: _______________ Postal Code: __________Country: ___________________

Bringing healthier and happier smiles to the children of the Dominican Republic