Special Smiles – Area Games Registration* denotes a required field.Gender*FemaleMaleName* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*Select CountyAlachuaBakerBayBradfordBrevardBrowardCalhounCharlotteCitrusClayCollierColumbiaDeSotoDixieDuvalEscambiaFlaglerFranklinGadsdenGilchristGladesGulfHamiltonHardeeHendryHernandoHighlandsHillsboroughHolmesIndian RiverJacksonJeffersonLafayetteLakeLeeLeonLevyLibertyMadisonManateeMarionMartinMercerMiami-DadeMonroeNassauOkaloosaOkeechobeeOrangeOsceolaPalm BeachPascoPinellasPolkPutnamSt. JohnsSt. LucieSanta RosaSarasotaSeminoleSumterSuwanneeTaylorUnionVolusiaWakullaWaltonWashingtonPhone*Email* Professional Role*-- Available Roles --DMDDMD StudentDDSDDS StudentResidentDental ResidentDental AssistantDental Assistant StudentRegistered Dental HygienistRegistered Dental Hygiene StudentSponsor TechnicianGeneral VolunteerAffiliation*Select AffiliationPrivate PracticeSelf EmployedCompanyCorporationCollegeUniversitySchool SystemGovernment AgencyOther AgencyAssociationOtherAffiliation NamePlease type in the proper name of the affiliation you selected above.Malpractice Insurance*Yes, I have malpractice insurance.No, I do not have malpractice insurance.Special Olympics offers coverage in North America thru a private insurance carrier. This coverage acts as a secondary coverage for health professionals who already have malpractice insurance. It will also act as primary malpractice insurance for health professionals who do not have malpractice insurance. In order to ensure that each volunteering clinician is covered both primarily or secondarily, we must know upon registration if you have coverage. If not, then Special Olympics Florida must send the names of those person to the insurance company prior to screening. You must also have a Florida license to practice in the state of Florida unless you are active duty in the military.Volunteer Opportunity*I'm registering to be a screening volunteer.I'm registering as a Clinical Director.Screening Event/Date*December 9 - OrlandoLunch will be served. Do you need a vegetarian option?*NoYesT-Shirt Size*Select T-Shirt SizeSmallMediumLargeXL2XL3XL4XL5XLNameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.