Dansie Orthodontics – September 30, 2017

The application is to be completed by the parent/guardian - the person legally authorized to make medical decisions for the child.
Child's Personal Information
Child's Full Name*
First (legal) Last (legal)
Child's Date of Birth (MM/DD/YYYY)*
MM slash DD slash YYYY
Child's Gender*
- Female
- Male
Child's Address*
Street Address City State / Province / Region ZIP / Postal Code Country

Please be sure to include the zip / postal code.

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Parent/Guardian's Personal Information
Parent/Guardian Name*
First Last
Best phone number to reach you at*
Is this number for
- home
- cell
- work
Email (required)*
*Email is the most effective way for SCL to communicate with you regarding your child's status. Please make sure this is a valid email address and that you notify SCL if your email address changes at any time. (Free email accounts are available through Google, Yahoo, etc. if you don't have one.)
Is your address the same as the applicant's?*
- Yes, same as above
- No, mine is different
Address*
Street Address City State / Province / Region ZIP / Postal Code Country

Please include your zip / postal code.
Marital Status*
Spouse/Partner/other Guardian's Name*
First Last Relationship to Child
If child doesn't live with both parents, name of non-custodial parent*

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Dental Health Certification
Good oral hygiene is a prerequisite for approval to the program ("good oral hygiene" means brushes and flosses regularly and does not have any known gum disease or unfilled cavities). Your child may be required to schedule a dental examination and cleaning if oral hygiene is a concern upon examination at a screening, and your child's application may be rejected if good oral hygiene is not attained to SCL's satisfaction.
Does your child have good oral hygiene?*
- Yes
- No
Is your child currently wearing braces?*
- Yes
- No
Does your child have a regular dentist?*
(a "no" answer does NOT disqualify your child from the program)
- Yes
- No
Name of Child's Dentist*
Practice Name*
Dentist's Phone Number*
Dentist's Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Dentist's Email*

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Financial Documentation
There are several documents required depending on your relationship to the child. *You have the option of uploading the documentation here or bringing it to the event with you. Either way is fine, but it must be received before your application will be considered complete.
What is your relationship to the child?*
- parent
- foster parent
- legal guardian
- Other
Foster Parents
*Note: As a foster parent, you do NOT have to submit your tax return. However, you do have to submit a copy of your medical authorization. For children in state custody, please submit a copy of their state medical card and consent.
Non-Parental Guardian Authorization Document
Drop files here or

Max. file size: 256 MB.
State Medical Card and Consent
Drop files here or

Max. file size: 256 MB.
Parents
You MUST submit a copy of the most recent year’s Federal Tax Form 1040 or Supplemental Security Income (SSI) award letter as proof of income (note: we do not accept Social Security benefits letters as proof of income).
- Submit Page one and two of Form 1040 (line 10, pg 2) must show total taxable income at or below the financial guidelines listed to qualify.
- The child applying MUST be listed as a dependent on either page one of Form 1040 or on Statement 1 along with the child’s Social Security number.
Click for additional information about financial requirements
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).
Federal Income Tax Form /or Supplemental Security Income Awards Letter
Drop files here or

Max. file size: 256 MB.
Additional Tax Return (if applicable)
Drop files here or

Max. file size: 256 MB.
Legal Guardian Authorization (not parent or foster parent)
Please upload a copy of the court order or legal documents giving you authority to make medical decisions for the child.
Upload legal authorization
Drop files here or

Max. file size: 256 MB.

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Explanation & Agreements
Why does your child want/need braces?*
check all that apply
- Teased or bullied because of teeth
- Difficulty eating or chewing
- Has pain in mouth and/or jaw
- Often has headaches
- Unable to clean teeth very well
Parent and child letter/explanation (Required)*
Include a short explanation from you and your child as to why the child wants/needs braces and what it would mean to them (make sure to include child’s full name). These can be typed or handwritten on a separate piece of paper. These will be shared with the screening orthodontist and is you and your child’s opportunity to explain what this treatment would mean to him/her and why they are a good candidate for the program.
Upload additional letters of support (optional)
These might come from a friend, family member, or a teacher. Please remember to include the child's name in the essay!
Drop files here or

Max. file size: 256 MB.
NOTICE OF PRIVACY PRACTICES*
- I acknowledge receipt of, and agree to, the SCL Privacy Practices
Click here to download and keep a copy of our Privacy Practices for your records.
PROGRAM RULES & GUIDELINES*
- I agree to the Program Rules & Guidelines
Click here to download and keep a copy of the Program Rules & Guidelines that you are agreeing to follow for your records.
CONSENT AND HOLD HARMLESS AGREEMENT*
- I agree to the Consent and Hold Harmless Agreement
Click here to download and keep a copy of the Consent and Hold Harmless Agreement for your records.
Full Name - Custodial Parent / Legal Guardian*
Date (MM/DD/YYYY)*
MM slash DD slash YYYY
Full Name - Child / Applicant*
Date (MM/DD/YYYY)*
MM slash DD slash YYYY

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Dansie Orthodontics – September 30, 2017

Apply for Smiles Change Lives

Step 1 of 8

Child's Personal Information

Parent/Guardian's Personal Information

Other Information

Dental Health Certification

Financial Documentation

Foster Parents

Parents

Legal Guardian Authorization (not parent or foster parent)

Explanation & Agreements

Photos Needed

CHANGING LIVES… ONE SMILE AT A TIME…

Alice W.

Alexandria W.

Tiffany L.

Daya G.

Judith W.

Alan P.

Joy S.

Shelly P.

Shelly P.

Joy S.

Alan P.

Judith W.

Daya G.

Tiffany L.

Alexandria W.

Alice W.