Click on Submit at the bottom of the page when you are ready to send this form to us. Alternatively, you may mail the form through USPS. The address is at the bottom of this page. Which country are you registering to participate in? None / Undecided Bolivia Guatamala Jamaica Uganda
Click on Submit at the bottom of the page when you are ready to send this form to us. Alternatively, you may mail the form through USPS. The address is at the bottom of this page.
Which country are you registering to participate in?
Please type the Month and Year of the outreach you are hoping to participate in: (example: January, 2007)
Your Contact information:
Your name: As it appears on your PASSPORT: Your preferred name or nickname? Mailing Address: City, State and 9 digit ZIP: Home Phone Number: Office phone: E-Mail Address: Passport Information: Passport number: Passport expiration date: Country that issued passport:
Your name: As it appears on your PASSPORT:
Mailing Address:
Home Phone Number:
E-Mail Address:
Passport Information:
Passport number: Passport expiration date:
Country that issued passport:
Roomate Information: I do not have a roomate and I understand that I may be charged a single supplement fee. Contact Smile Power for details.
Interest in optional side trip (not always offered) Yes, if space is available I am interested in the optional side trip.Contact Smile Power for details.
Please tell us your specialty and/or occupation: Also, please describe any specific interests/skills that we should consider in organizing your projects
Incase of emergency, who should we contact? Please provide the name, full address, phone number and relationship of this person to you:
Emergency contact name:
Address to reach them at:
Allergies / Medical conditions Do you have any allergies or other medical conditions that we should be aware of?
Are you in any way associated with rotary? Yes No
Additional Comments:
Carlson Wagonlit Travel Service or other travel service used and the International Smile Power are only agents for the participants of the program and the participants hold them free of liability for any injury, delay, or damage for any cause whatsoever. I HAVE READ THE ENTIRE FORM AND ACCEPT ALL TERMS AND CONDITIONS SPECIFIED. Yes, I accept all terms and conditions as specified No Checking the above button "yes" equals a signature. Date: MM-DD-YYYY
Signature _____________________________________________________________________________________________ (Signature is only necessary if you will be mailing this form through USPS)
This form can be submitted electronically by clicking "submit" below. Alternatively, you may print out the form and mail it to:
International Smile Power 704-228th Ave NE PMB #204 Sammamish, WA 98074
E-Mail( Office Administrator) : smilepower@smilepower.org