*First Name:

*Last Name:

*Phone:

*Email:

*Name of Organization/Dental Office:

*Street Address:

*City:

*State:

*ZIP code:

*Number of kits requested:

Purpose for which the kit will be used:

Will the kit be used for a specific event? If yes, please explain:

Is there a specific date that the kit is needed by? Please explain:

How did you hear about the kit?:

*A $200 donation (per kit) to the Delta Dental Foundation will help to cover the cost of another kit that we will provide to an organization/group in need. We will mail your kit out immediately upon receiving your check.

Please make checks payable to the Delta Dental Foundation and send to the following address:

Delta Dental Foundation
Attn: Emily Waldschmidt
4100 Okemos Rd.
Okemos, MI 48864

*The Delta Dental Foundation is no longer offering kits to rent.