Rethink Your Drink Display Kit Request Form

First Name* Last Name*
*
*
Street*
 
City* State*
 
ZIP code* Country*
Purpose for which the kit will be used*
Will the kit be used for a specific event? If yes, please explain
*

PLEASE NOTE: Due to high demand, we are unable to guarantee that a kit will be available on the exact date that you requested above.

Please select one*

*All borrowed kits must be returned within 30 days of receiving them. For your convenience, a pre-paid return address label is included.
*A $200 donation to the Delta Dental Foundation will help to cover the cost of another kit that we will provide to an organization/group in need.  We will mail your kit out immediately upon receiving your check.

Please make checks payable to the Delta Dental Foundation and send to the following address:

Delta Dental Foundation
Attn: Katie Frankhart
4100 Okemos Rd.
Okemos, MI 48864