2024-2025 USA Club Registration
CLUB INFORMATION
Please note, this needs to be completed every school year!
You will receive an email confirmation once submitted.
1.
Question - Not Required -
School Type
Please select response
Elementary/Grade
Lower/Middle
High School
University
Medical School
Other
*
2.
Question - Required -
School/Club Name
*
3.
Question - Required -
School Address (i.e. 1234 Smile St)
*
4.
Question - Required -
School City
5.
Question - Not Required -
Club Facebook Page
*
6.
Question - Required -
School State
Please select response
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
*
7.
Question - Required -
School Zip Code
*
8.
Question - Required -
Are you registering a new club?
Please select response
Yes
No
*
9.
Question - Required -
Approximate Number of Club Members
LEADERSHIP INFORMATION
*
10.
Question - Required -
Primary Student Contact Name
*
11.
Question - Required -
Primary Student Contact Email
*
12.
Question - Required -
Primary Student Contact Phone Number
*
13.
Question - Required -
Primary Student Contact Graduation Year (ex: 2020)
*
14.
Question - Required -
Secondary Student Contact Name
*
15.
Question - Required -
Secondary Student Contact Email
*
16.
Question - Required -
Secondary Student Contact Phone Number
*
17.
Question - Required -
Secondary Student Contact Graduation Year (ex: 2020)
*
18.
Question - Required -
Advisor/Moderator/Teacher Name
*
19.
Question - Required -
Advisor/Moderator/Teacher Email
*
20.
Question - Required -
Advisor/Moderator/Teacher Phone Number
WEBSITE & SOCIALS
21.
Question - Not Required -
School Website
22.
Question - Not Required -
Club Instagram Page
23.
Question - Not Required -
Other Club Social Media Handle(s)
OPERATION SMILE SUPPORT
If you haven't done so already, please connect with your associate to stay up to date with all things Operation Smile!
Melissa Cagney (melissa.cagney@operationsmile.org) - western region
Mansi Shah (mansi.shah@operationsmile.org) - northern & southern region
MaryAnn Lafler (maryann.lafler@operationsmile.org) - virginia
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