Project Mariposa Application

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 Ethnicity
- Caucasion
- African American
- Hispanic
- Asian
- Native American
- Other
Child's Gender*
- Female
- Male
Child's Address*
Street Address City State / Province / Region ZIP / Postal Code Country

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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 us to communicate with you regarding your child's status. Please make sure this is a valid email address and that you notify us 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 a primary dentist?*
*Please note: a Dental Referral Form is required to be completed by a General Dentist prior to acceptance into the Project Mariposa Program. If you check "no", that your child does not have a dentist they see on a regular basis, then you will need to send an email to info@smileschangelives.org with complete contact info for the dentist your child will be visiting. (dentist's name, practice name, address, phone, fax, and email.)
- Yes
- No
Does your child have good oral hygiene?*
- Yes
- No
What was the date of their last cleaning?*
Is your child currently wearing braces?*
Please note: If your child is currently wearing braces, they do not qualify for the SCL 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
This info is very helpful if you are able to obtain it. It allows us to get information about the program out so that more children can be helped. As we are unable to call everyone, email is the most efficient method of contact.

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Financial Documentation
There are several documents required depending on your relationship to the child.
HELPFUL HINT: If you do not have a digital copy of the required documentation, you have several options including: 1. Go to your local library or ask a friend to scan it for you. 2. Photograph the required documents or pages using your cell phone and upload the images. 3. Go to the program overview page and download an application to be completed and mailed in.
What is your relationship to the child?*
- Parent
- Foster Parent / Foster Agency / State Agency
- Legal Guardian
- Other
Foster Parents
*Note: As a foster parent or agency, you do not have to submit your tax return. However, you do have to submit a copy of medical authorization. For children in state custody, 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 a Supplemental Security Income (SSI) award letter as proof of income (US) or a T4 and a Tax Assessment form (Canada) [Note: we do not accept Social Security benefits letters as proof of income.]
- Line 10, pg 2 on 1040 must show total taxable income at or below the financial guidelines listed to qualify.
- The child applying MUST be listed as a dependent on page one of Form 1040 along with the child’s Social Security number.
Click for additional information about financial requirements and to see an example.
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
- none of the above (can explain in the comments later)
Parent and Child Letter/Explanation (Required)*
Include a short explanation from you and one from 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.
HELPFUL HINT: The next three boxes contain very important information. Once you read them all the way to the end, you will be able to click the boxes.
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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Application Fee*
The $30 non-refundable application fee is required for the application to be considered complete
Price:
Coupon
Total
$0.00
Please enter your payment info below. You may use either a debit or credit card.
[We use PayPal for our credit card processing. Your information is encrypted and secure.]
Credit or Debit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
When your application arrives at the Project Mariposa office, it will be reviewed to determine if it is complete, and if your child meets our program’s requirement guidelines. In some cases, the applications are submitted to a review panel. Those that are determined to qualify, will be notified via both US Mail and through email. This process can take up to three weeks. Please be patient. If any part of the application is missing or is incomplete, you will receive one email from us requesting the missing or incomplete information. If you do not respond to that email with the requested information, within the allotted time, your application is then deemed incomplete and you will need to reapply if you wish for your child to be considered through our program.
NOTE: Only hit the "submit application" button once...even if you get a gateway timeout error. (If you hit the “Submit Application” button again, it will submit another copy of your child’s application, as well as charge your credit card another $30.) *You will receive an email confirmation within 24-48 hours. Be sure to check your ‘junk’ or ‘spam’ folders too. (Sometimes different servers block our confirmation receipts and we have no control over this, but we are working with our provider to correct this issue.) If you still are not certain we have received your child’s application after 48 hours, send an email to info@smileschangelives.org and we can let you know if it is here and under review.

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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

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