Land of Smiles® Program Curriculum
Free Books for Classroom Form

Thank you for providing the Land of Smiles® curriculum to your students. If each of your students completed their monthly brushing and flossing chart as part of the completed curriculum, please complete this short form to receive free books for your classroom.

Please note: Delta Dental will provide books for the classroom to use, not for each individual student.

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* 1. School name:

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* 2. Your name:

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* 3. Job title:

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* 4. Email address:

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* 5. Number of students in your classroom?

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* 6. When did your students complete their monthly brushing and flossing charts?

Please select date completed.

Date

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* 7. Please select all books you would like to receive.

Clark the Shark: Tooth Trouble by Bruce Hale

Oh, The Things You Can Do That Are Good for You: All About Staying Healthy by Tish Rabe

Tooth Book: A Guide to Healthy Teeth and Gums by Edward Miller

Trip to the Dentist by Penny Smith

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* 8. Shipping address:

School Name

Address *

Address 2

City *

State *

ZIP Code *