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        _____  Pantoja,Sto 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: ______________