Skip to content
Home
About
Why Services Like These Are Needed
Our Program
Our Happy Team
Our Dental Partners
Our Sponsors
Smile Makers
Completed Smile Projects
Our Schools
Lake Orion Community Schools
Lapeer Community Schools
Waterford School District
News
Contact
How Can Dentists Support Our Mission?
Home
About
Why Services Like These Are Needed
Our Program
Our Happy Team
Our Dental Partners
Our Sponsors
Smile Makers
Completed Smile Projects
Our Schools
Lake Orion Community Schools
Lapeer Community Schools
Waterford School District
News
Contact
How Can Dentists Support Our Mission?
Donate Now
Make A Donation
Home
About
Why Services Like These Are Needed
Our Program
Our Happy Team
Our Dental Partners
Our Sponsors
Smile Makers
Completed Smile Projects
Our Schools
Lake Orion Community Schools
Lapeer Community Schools
Waterford School District
News
Contact
How Can Dentists Support Our Mission?
Home
About
Why Services Like These Are Needed
Our Program
Our Happy Team
Our Dental Partners
Our Sponsors
Smile Makers
Completed Smile Projects
Our Schools
Lake Orion Community Schools
Lapeer Community Schools
Waterford School District
News
Contact
How Can Dentists Support Our Mission?
Donate Now
Fill Out Our Form Below To Start The Applicant Process:
Apply Today
Application
Child's Information
Full Name
*
Date of Birth
*
Home Address
*
Home Address
Home Address
Home Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Home Address
Parent / Legal Guardian Information
Full Name
*
Date of Birth
*
Phone
*
Email
*
Relationship to Child
*
Employer Name
*
Home Address
*
Home Address
Home Address
Home Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Home Address
Child’s Dental Information
Approximate Date of Last Dental Visit
*
Name of Dentist
*
Dentist’s Phone Number
*
Describe any current dental concerns:
*
Household Information
Monthly Household Income:
*
(Paystubs from the past two months will be required.)
Monthly House or Rent Payment:
*
Are you currently receiving any financial assistance?
*
Yes
No
Total number of people living in the household:
*
Please list the name, age, and relationship of each household member:
*
Please list all applicable programs (e.g., unemployment, workers’ compensation, Social Security retirement, SSI, SSDI, etc.):
*
Certification
I certify that the information provided in this application is true and complete to the best of my knowledge.
*
Yes
Signature
*
signature
keyboard
Clear
Type Full Name
*
Application Checklist
Please ensure all required documents are included with your submission:
*
Completed Happy Teeth Application (this form)
Signed Happy Teeth Photo Consent Form (
download
)
One Character Reference Letter
Upload Photo Consent Form and or Character Reference Letter Below:
Drop a file here or click to upload
Choose File
Maximum file size: 1MB
Submit
If you are human, leave this field blank.
