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GKAS – Host an Event
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GKAS – Host an Event
GKAS – Host an Event
GKAS - Host an Event at Your Clinic (2025)
Clinic Name
(Required)
Contact Name
(Required)
First
Last
Contact Title
(Required)
Dentist
Dental Therapist
Dental Hygienist
Dental Assistand
Clinic Administration
Other
Contact Email
(Required)
Clinic Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
What COUNTY is your clinic in?
(Required)
District Dental Society
Minneapolis District
Northeastern District
Northwestern District
Saint Paul District
Southeastern District
Southern District
West Central District
Student District
Is your clinic part of an educational facility (dental hygiene school, for example) or a community public health clinic?
(Required)
Yes
No
Event Date
MM slash DD slash YYYY
From
Hours
:
Minutes
AM
PM
AM/PM
To
Hours
:
Minutes
AM
PM
AM/PM
Second Event Date (If applicable)
MM slash DD slash YYYY
From
Hours
:
Minutes
AM
PM
AM/PM
To
Hours
:
Minutes
AM
PM
AM/PM
What services do you plan to provide to children? Please list specific services like this example: Exams, cleanings, fluoride varnishes, sealants, x-rays, fillings, extractions.
If your clinic will have translators on hand during your event, what languages will be addressed? (Please list, for example, Spanish, Vietnamese, Somali, etc.)
How many children to you plan to schedule on Day 1?
(Required)
How many children to you plan to schedule on Day 2 (if applicable)?
(Required)
If you are not holding an event on a second day, please enter 0.
Number of total volunteers from your clinic (including dentists):
Please list the full names of the DENTISTS who will be volunteering:
Would you like the MDA’s assistance in identifying volunteers to help at your clinic?
Yes
No
If you answered YES to the above, please describe what type of professional services are needed and during what time/date. For example: “We need 2 dental hygienists to help out from 1 to 4 p.m. on Feb. 4.” Please also recruit volunteers from within your network of colleagues as, unfortunately, the MDA cannot guarantee it will find a volunteer for your clinic.*
Would you like the MDA’s assistance in informing families about your event?
(Required)
Yes
No
Families should call this number to make an appointment:
(Required)
Clinic Website
Letter of Understanding
(Required)
I agree to the Letter of Understanding
Give Kids a Smile
United Way and MDA website listing
Letter of Understanding
Please read and sign this letter only if your clinic’s name will be listed with the United Way 2-1-1 service and the MDA website. Many clinics have had positive experiences with this special aspect of the “Give Kids a Smile” program. But, based on questions and concerns we’ve received in the past, the MDA feels that clarification about this service is necessary. Thank you for your cooperation.
1. The MDA works with a free public central phone referral service, United Way 2-1-1, as a key means of informing families about which dental clinics are accepting appointments for “Give Kids a Smile” services. The listing includes your clinic name, phone number, date and office hours for “Give Kids a Smile,” as well as services provided. Identical information is listed on the public portion of the MDA website. The MDA strategically promotes these lists as it advertises the “Give Kids a Smile” program.
2. Trained referral specialists at the United Way 2-1-1 centers take calls from the public and ask basic questions in order to identify which clinics might be the best choice for families, dependent on location of the clinic and services provided. Parents then call the clinic to make an appointment for their child.
3. Patients are not screened for dental needs. However, some families may know if their child has severe need or pain vs. the need for an exam. This is discussed only in the context of finding a clinic that offers restorative services or preventative services.
4. Give Kids a Smile is a charitable program that does not have any financial eligibility requirements. The MDA requires that clinics on this list not ask parents any questions about their ability to pay, patient status, or discriminate in any way.
5. One of the great things about posting your clinic’s name with United Way 2-1-1 and on the MDA website is flexibility. When your appointment schedule for the day is full, please notify the MDA immediately and we will remove your name from the list. If you have appointment spots that open up, we can place your clinic’s name back on the list - all within a few moments. Please work directly with the MDA. Please do not call United Way 2-1-1 directly, as that initiates additional steps for its staff.
By selecting “I agree,” you are confirming that you have read and understood the instructions involved in posting your clinic’s name on the United Way 2-1-1 list and on the MDA website. If you have any questions, please contact the MDA at 612-767-8400. Thank you!
Please print and save this document for future reference. https://www.mndental.org/files/GKAS-Letter-of-Understanding.pdf
Name
This field is for validation purposes and should be left unchanged.