Apply For Braces
NOTE: SCL only accepts the current version of our application. Download a current application by clicking the button above. In addition, all applications received will be subject to the most current fee structure regardless of the fees specified on the application submitted.
Current Fee Structure:
- $30 Application Fee
- $600 Program Fee
Smiles Change Lives (SCL) connects caring orthodontic providers with qualified children in need of braces. Approved families agree to pay a $600 Program Fee* for access to SCL’s provider network. SCL orthodontic providers offer quality treatment and healthy smiles to children approved for our program. Children applying for our program must meet the qualifications noted below and be motivated to follow their orthodontist’s treatment plan, which averages between 20 and 36 months.
Children and families are welcome to apply for treatment through SCL, regardless of where in the U.S. they reside. SCL works with families and treatment providers in all fifty (50) states. To see if there is a treatment provider in your area, please visit our Provider Directory.
NOTE: SCL provides for orthodontic treatment ONLY. Extractions, cleanings, oral surgery or other treatment that may be necessary before, during or after orthodontic treatment are the financial responsibility of the patient’s parents or guardians.
If you have any questions about the application process, please email us at firstname.lastname@example.org. Email is the best and fastest way to reach us; emails will be replied to within 3 working days. If you are unable to email us, you can call and/or leave a voicemail during our designated phone hours, at 888-900-3554.
- Be 10-18 years of age;
- Have no more than four (4) baby teeth;
- Have “good” dental hygiene (as certified by the applicant’s general dentist);
- Have no unfilled cavities;
- Not be wearing braces currently; and
- Have a total household income at or below 200% of the Federal Poverty Level; You can determine whether or not you meet the financial requirements by visiting http://www.smileschangelives.org/financial
- Be willing to pay the $30 application fee and the $600 program administration fee (per child)
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Smiles Change Lives2405 Grand, Suite 300Kansas City, MO 64108
- Click the “Download Application” button
- Print the application
- Fully complete all portions of the application
- Mail the completed application, along with all additional required documents to:
Please ensure you use adequate postage and keep a copy of the entire application for your records.
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In order to be considered for the SCL program, all of the items below must be fully completed and submitted to SCL for each child that is applying to the program. Please use the checklist below to ensure you’ve included each of the required documents; that each has been fully completed; and that all items are signed where required.
Because the need for assistance goes beyond our ability to ensure treatment for every applicant, the SCL acceptance policies are very strict. If your application is incomplete in any way, it will be rejected and returned to you. If you wish to reapply you will be required to submit a new application with an additional $30 application fee.
□ $30.00 non-refundable application fee (personal check, cashier’s check or money order; made payable to Smiles Change Lives)
□ Child’s Application (pg. 3)
□ Parent/Guardian Application (pg. 4)
□ Notice of Privacy Practices (pg. 5 - Must be signed by parent/guardian)
□ Program Rules and Guidelines (pg. 6 - All items must be initialed by parent/guardian)
□ Parent/Legal Guardian Consent & Child Consent (pg. 7 – Must be signed by BOTH parent/guardian & child)
□ Dental Referral Form (pgs. 9-10 - Must be FULLY completed by the child's general dentist or dental hygienist based on an exam no more than six (6) months prior to the application date. Must show good dental hygiene and no unfilled cavities)
□ Federal Tax Form 1040/1040A/SSI Awards Letter - Proof of income MUST be submitted in the form of either a COMPLETE copy of the most recent year's federal tax return (include ALL pages, schedules, or statements) AND/OR a copy of a current SSI awards letter. Tax forms/SSI awards letters that are altered in any way, including removing/blacking out Social Security numbers, will NOT be accepted. If you are submitting applications for more than one child, you MUST include a copy of your tax return/SSI Awards letter with EACH application.
If submitting Form 1040/1040A, please note:
- The child applying for treatment MUST be listed as a dependent on either page 1 of Form 1040/1040A or on Statement 1 along with the child's Social Security number.
- If the child is NOT claimed as a dependent on your tax return, you must explain why and ALSO 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 tax returns must meet our income qualifications.
- Page 2 of Form 1040/1040A (line 43 on 1040 and line 27 on 1040A) must show total household income at or below 200% of the Federal Poverty Level.
- If your income does not require you to file taxes, but you are legally allowed to file, you must do so in order to apply for our program, even if your income is $0.
□ Optional: Personal essay from the child and/or letters of support detailing why the child wants braces, how they feel their life might be improved as a result of treatment, etc (This is optional but encouraged)
*** Additional documentation for non-parental guardians
□ Non-parental guardians must also submit a copy of their authorization to make medical decisions.
□ For children in state custody, copies of the child's state medical card and medical consent must also be submitted.
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You must have Adobe Reader to download the application. Download Adobe Reader here.
Do you live in Coffey, Lyon or Osage County in Kansas? Please visit our Jones Foundation page to download an application for braces.