2021-2022 School Year  
  Confirmation of Masonic Lodge Participation  

YES! We want to offer the Fantastic Teeth Fan Club to first graders in our area. Please complete the form below. Please call us at 817.503.1500 with any questions.    
Select Lodge:    
Lodge Contact Name:    
Preferred Phone:  
Lodge Contact Email:
Lodge Email:    
  SHIPPING ADDRESS (No PO Box or Lodge Address please):    
City: Zip:
  PLEASE PROVIDE AN ALTERNATIVE CONTACT PERSON in the event we are unable to reach you.    
Alternate Lodge Contact Name:    
Preferred Phone:    
School Name(s) and School District Name(s):
List the schools and school districts your Lodge would like to sponsor; new schools based on availability.
MCFS will contact the schools regarding the program. Please do not contact the schools yourself.
List School Name(s) and School District Name(s):
Additional Notes:
Month you would prefer to distribute the kits (please list at least 3):
MCFS will do our best to honor this request in light of the ongoing COVID-19 related school restrictions throughout the state.
Your signature below confirms your understanding of the Fantastic Teeth Fan Club and your Lodge participation (Terms of Acceptance):
  • We understand that, although MCFS will make every effort to invite local schools to participate, we cannot guarantee school participation
  • We understand that our Lodge will deliver kits to schools in our area.
  • We understand that MCFS will provide up to 300 free prevent tooth decay kits per Lodge. MCFS will provide information on the number of local first graders approved for the program. At that point, if our Lodge wishes to sponsor more children, we can make a donation to cover the cost of additional kits for the ISD. ($2.85 per kit, includes shipping and handling). There is no obligation to make a donation for additional kits.
We understand that the FTFC program may be impacted by ongoing COVID-19 challenges and we agree to be flexible to changes that may arise as a result.
We agree to do our very best to assemble and deliver the dental kits to our schools as quickly as possible once we receive our shipment of materials from MCFS.
Electronic Signature*
Please type your First and Last Name