OUR SUCCESS IS MEASURED BY THE EXTENT OF YOUR SMILE
 Dr. ZAK
Sea Breeze

Dental Care
CONTEST ENTRY FORM

Dr. Zak is sponsoring this Good Samaritan contest, designed to reward kids and teens of for their good deeds and acts of kindness toward others. You must be 18 years old or under to enroll in this contest.

Instructions:
Do ANYTHING - anything which helps your family, friends, neighbors, city, school, etc. Simply Perform an Act of Kindness- big or small and tell us about it.

For your contest entry, write a half to one page essay explaining your Act of Kindness. These acts can be a one-time occurrence, or a recurring event. Please include the following:

    1. What did you do?
    2. Why did you do it?
    3. What were the consequences of your actions? What resulted from it?
    4. Who benefited and how?

You must complete the entry form in all required fields truthfully in order to qualify.

Winners will be notified by e-mail, mail, or telephone and winners will be posted on our website, at their own discretion. If you are the winner, you will receive the new iPod Touch!
Deadline: March 30th.



Your Information:
 
First Name: * Last Name: *
Gender: * Age : *
Street Address: *
Street Address 2:
City: *
State: *
Zipcode: *
Country: *
Phone: * Email : *

Your Good Deed
 

Type or paste your Good Deed Essay below. Deed can be a one-time occurrence, or a recurring event. Please include the following:

  1. What did you do?
  2. Why did you do it?
  3. On what principles did you base your actions? (e.g. President Theodore Roosevelt once said, "..." or my mom always says, "...")
  4. What were the consequences of your actions? What resulted from it?
  5. Who benefited and how?

Parent Information
 
Mom's Name: * Dad's Name: *
Home Phone: *

School Information
 
School:
Principal's Name:
School Phone:
School Address:
City:
State:
Zipcode:
 

Enter the name of the doctor who is running the contest in your area. Leave blank if not applicable or if doctor's name is unknown. A blank field does not mean that you do not qualified.

 I acknowledge and accept that my essay may be used by ZakDental.com for sharing publicly, without revealing my private information.

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