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):
If Business, Type Business Name:
Name:
Address:
City:	Zip:

	Worshipful Master Information
Name:
Email:
Preferred Phone:

	PLEASE PROVIDE AN ALTERNATIVE CONTACT PERSON in the event we are unable to reach you.
Alternate Lodge Contact Name:
Email:
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):

Schools same as last year.

Additional Notes:

Month you would prefer to distribute the kits (please list at least 3):

If your Lodge would like to participate in the FTFC Program each year, please check this box and MCFS will contact the Lodge annually to schedule the program.

Your signature below confirms your understanding of the Fantastic Teeth Fan Club and your Lodge participation (Terms of Acceptance):

We understand that, MCFS will make every effort to invite local schools to participate.
We understand that our Lodge will deliver kits to schools in our area within the month selected.
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).
If for some unforeseen reason our lodge cannot deliver the kits withing the selected month, we will notify the lodge coordinator promptly.

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.

TERMS OF ACCEPTANCE and SIGNATURE

Electronic Signature*

Please type your First and Last Name

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.