bracing kids
for a better future…
Search for:
Search for:
Home
About
Our-Story
Our Board
Our Team
Our Sponsors
For Kids & Parents
Apply For Braces
Benefit of Braces
FAQs
Foster Kids & Families
Success Stories
For Orthodontists
Provider Overview
Provider FAQs
Become an SCL Provider
Provider Directory
Provider Testimonials
Participating Dental Schools
SCL Provider Login
For Dentists
Become A Referral Partner
Refer A Child/Family
Testimonials
Success Stories
Provider Testimonials
Smile Contest Stories
Donate
Get Involved
Refer A Child/Family
Volunteer
Become A Sponsor
Become A Business Partner
News
E-News
SCL Events
Smile Contest Stories
Orthodontist Of The Week (OOW)
Blog
Contact
SCL Application for White Brown Smiles screening event
Step
1
of
7
0%
Due to overwhelming response, we can only accommodate the first 100 families who submit an application showing their child is qualified for SCL. br> br> Please note this event is only for children residing within the greater Columbia, SC area who qualify for Smiles Change Lives’ program. br> br>
Please complete a separate application for each child. br>
The application is to be completed by the parent/guardian - the person legally authorized to make medical decisions for the child.
br> br>
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Please be sure to include the zip / postal code.
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Please include your zip / postal code.
Marital Status
*
Married
Domestic Partnership
Separated
Divorced
Single
Widowed
Spouse/Partner/other Guardian's Name
*
First
Last
Relationship to Child
If child doesn't live with both parents, name of non-custodial parent
*
Other Information
How did you first hear about Smiles Change Lives (SCL)?
*
special SCL screening event at orthodontic office
Web / Google search
Current SCL Participant
Family / Friend told me about it
Link from another website
General Dentist
Dental Clinic / Dental School
Orthodontist
Other
Location and Date of event
What word(s) did you use for your search?
SCL Participant Name(s)
Name of friend or family member
Name of website where you found the link
Name of dentist and practice name
Name of dental clinic / dental school
Name of orthodontist / practice name
Please explain:
Have any of the child’s family members applied to or been treated through SCL?
*
Yes
No
Please list their name(s)
We attempt to place children as close as possible but search up to a 100 mile radius for available treatment providers. If necessary, are you willing to travel farther?
*
Yes
No
Please list any health issues your child has that we should be aware of:
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Dentist's Email
*
Financial Documentation
There are several documents required depending on your relationship to the child. br> br>
What is your relationship to the child?
*
parent
foster parent
legal guardian
Other
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
Select files
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
Comments / Questions
We will email you that this information was received as well as directions if we are able to accomodate you for the screening event. Only those notified will be able to be screened at this event due to the overwhelming response. (If you do not receive an email, please check your spam/junk folder.)