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Smiles Change Lives and White Brown Smiles event (for overflow registrations)

Parent / Guardian Name*
First Last
Child's Name*
First Last
Child's Age*
- 0 to 6 years old
- 7 to 21 years old
- 22 years old or older
Email*
Mobile Phone*
How did you learn about the event*
- Flyer (school, church, organization, etc.)
- Facebook
- Google Ad
- A friend told me
- my general dentist
- newspaper article
- TV/Radio
- SCL newsletter
- Other
Please explain
What is your household size (# of dependents)?*
- 2
- 3
- 4
- 5
- 6
- 7 or more
What is your household taxable income?*
- $40,599 or less
- $40,600 - $51,049
- $51,050 - $61,499
- $61,500 - $71,949
- $71,950 - $82,399
- more than $82,400
Comments / Questions

CHANGING LIVES… ONE SMILE AT A TIME…

Alice W.

"Our son would have gone without braces if it wasn't for SCL! Thankful for this program and staff that care. We are currently in treatment. It is already making a difference. "

Alice W.

Alexandria W.

"Amazing program that has truly changed my life. Once I was accepted it was such an easy process. Thank you so much!! I would recommend any one with low income and bad teeth to go through the process."

Alexandria W.

Tiffany L.

"Just had our last appointment. Being a school teacher I didn't make a lot of money. This program allowed me to give my daughter a smile that she shares with everyone. Thanks."

Tiffany L.

Daya G.

"I just had not one but two daughters finish having their braces on through Smiles Change Lives and we are so happy with the results. Thank you for providing this service!"

Alice W.

Judith W.

"This is an incredible organization with Orthodontists donating their skills to change children's lives. More people in need should know about this fantastic program"

Judith W.

Alan P.

"My son has finally been accepted, approved, and assigned an orthodontist. He goes tomorrow for his first appointment to start getting his braces. Thanks SCL, you have made my son very happy."

Alan P.

Joy S.

"I am so thankful for smiles change lives for helping a struggling mother out. What an amazing program that helps families."

Joy S.

Shelly P.

"I cannot say enough GREAT things about this program! They have given both of my daughters a new outlook on life, & self confidence that I could never teach."

Shelly P.

Shelly P.

"I cannot say enough GREAT things about this program! They have given both of my daughters a new outlook on life, & self confidence that I could never teach."

Shelly P.

Joy S.

"I am so thankful for smiles change lives for helping a struggling mother out. What an amazing program that helps families."

Joy S.

Alan P.

"My son has finally been accepted, approved, and assigned an orthodontist. He goes tomorrow for his first appointment to start getting his braces. Thanks SCL, you have made my son very happy."

Alan P.

Judith W.

"This is an incredible organization with Orthodontists donating their skills to change children's lives. More people in need should know about this fantastic program"

Judith W.

Daya G.

"I just had not one but two daughters finish having their braces on through Smiles Change Lives and we are so happy with the results. Thank you for providing this service!"

Alice W.

Tiffany L.

"Just had our last appointment. Being a school teacher I didn't make a lot of money. This program allowed me to give my daughter a smile that she shares with everyone. Thanks."

Tiffany L.

Alexandria W.

"Amazing program that has truly changed my life. Once I was accepted it was such an easy process. Thank you so much!! I would recommend any one with low income and bad teeth to go through the process."

Alexandria W.

Alice W.

"Our son would have gone without braces if it wasn't for SCL! Thankful for this program and staff that care. We are currently in treatment. It is already making a difference. "

Alice W.

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