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Smile for a Lifetime Online Application
The information in this application is needed to fulfill your request for assistance with orthodontic treatment. We may share this information with orthodontists, dentists, or other dental professionals to process your scholarship application. Once you have completed the application, please review carefully before you submit. Information is not saved and must be completed in one sitting. Please return the Dental Clearance Form, Letter of reference, Report Card, Proof of Income and Facial Photos by email to Info@SmileForALifetime.org or by fax to 719-312-6000. If all the needed information is not submitted within 30 days, you may be required to start the application process over. The approval process can take 6 to 12 months from the time you have turned in ALL the needed paperwork. The application process is competitive and not all qualified applicants will be guaranteed a scholarship.
APPLICANT'S PERSONAL INFORMATION
Applicant's Name:
*
First Name
Last Name
Applicant's Age
*
Date of Birth
*
Applicant's Ethnicity
*
Gender
*
Is the applicant in Foster Care or Out of Home Placement?
*
Yes
No
Applicant's Address
*
Street Address
Street Address Line 2
City
State: U.S. Residents Only
Postal / Zip Code
PARENT/GUARDIAN’S PERSONAL INFORMATION
Parent or Guardian Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State: U.S. Residents Only
Postal / Zip Code
Phone Number
*
-
Area/Country Code
Phone Number
Contact E-mail
*
Confirmation Email
Marital Status
*
Married
Single
Separated
Divorced
Relationship to Child
*
Parent
Legal Guardian
Foster Parent
If child doesn’t live with both parents, name of non-custodial parent
*
FOR NON-PARENTAL GUARDIANS, you MUST submit a copy of your medical authorization (e.g, court order, letter of authorization, etc.). For children in state custody, submit a copy of their state medical card and consent.
*
I understand
I do not understand
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DENTAL INFORMATION
Does your child have a Primary Dentist?
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Yes
No
Dentist's Name
*
First and Last
Last Oral Cleaning?
*
Under 6 months
Under 12 months
Under 24 months
Please list any health issues your child has that we should be aware of
*
Do you have Orthodontic Insurance? If so, how much does it cover? (This will NOT hold you back from receiving a scholarship)
*
Have any of the child’s family members applied to or been treated through Smile for a Lifetime? If so, please list their name(s) and the name of the orthodontist who treated them
*
Is your child currently wearing braces?
*
Yes
No
Why does your child want braces?
*
Difficulty eating or drinking
Pain in mouth or jaw
Teased for appearance
Other
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GENERAL INFORMATION
Is your child currently enrolled in school?
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Yes
No
Is your child currently enrolled in home school?
*
Yes
No
Grade:
*
GPA
*
Name of School
*
How many people are in your household?
*
Number of Adults
*
How many of those adults are employed?
*
Number of Children
*
Did any parent or guardian file Federal Taxes last year?
*
If so, who?
If the child applying is not claimed as a dependent on your tax return, you must explain why and submit the tax return for the person who DOES claim the child, as well as proof of where the child resides (e.g. school records). In this situation, BOTH parents are required to submit proof of income, each must separately meet our financial qualifications
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I do not understand
What is the household taxable income, please provide? (Must match last year's tax returns, if 0 please explain)
*
Was your family's income negatively affected by COVID 19? If so, please explain.
*
Do you receive or pay any child daycare, child support, alimony, medical expense, etc?
*
If so, please explain
Form of Transportation (For Appointments)
*
Car, bus, etc.
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How did you hear about us?
*
Comments? Thank you
Thank you!
I acknowledge that Smile for a Lifetime will be sending my information to local orthodontists and dental professionals to locate a provider in my area.
*
I acknowledge
I do not acknowledge
Once you have completed this application you understand that you have 30 days to submit the listed documentation listed from our website to be considered. The $20 application fee is non-refundable.
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I understand
I do not understand
Application Fee
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( X )
Application Fee
$
20.00
I understand that once I apply the Application Fee is Non-refundable.
Total
$
0.00
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