Application

EMBRACING OUR WARRIORS

Thank you for applying for the Smile Service Award through Embracing Our Warriors. Your completion of this application is essential for us to facilitate your request. In processing your application, we may need to share the provided information with orthodontists, dentists, or other dental professionals. Please review the application thoroughly before submission, as information cannot be saved and must be completed in a single session. After you have completed your online application, you will need to submit the following documents; Proof of Honorable Discharge from Service (DD214), VA Disability Award Letter, Dental Clearance Form, Proof of Income, Share Your Story form, and Facial Photos via email to Info@EmbracingOurWarriors.org. Failure to submit all required information within 45 days may necessitate restarting the application process. Please note that the approval process typically spans 3 to 6 months from the submission of all necessary paperwork. It's important to recognize that while the application process is competitive, not all qualified applicants are guaranteed an award. We appreciate your understanding and patience throughout this process.
To help support our mission, a small application fee is required. A non-refundable $25 application fee is collected at the end of this form to help offset the cost of processing each application.

If your application is approved to proceed and we are able to locate a participating orthodontist in your area, you will be charged an additional $200 matching fee to finalize your placement. This fee helps sustain our program and allows us to continue serving more families in need.

Once matched and approved, your full orthodontic treatment is completely free, including braces and a retainer after your treatment is complete.
MILITARY SERVICE INFORMATION
Name of Member who served in the military *

First NameLast Name
Do you have a service related disability?*
Which branch of the military did you serve?*

APPLICANT NEEDING ORTHODONTIC TREATMENT
Name of Applicant Receiving Orthodontic Treatment *
Applicant's relationship to Service Member*
Age of person receiving Treatment *
Date of Birth of person receiving treatment*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
If applying for your child, please include parent's name

First NameLast Name
If your address is different then the child, please provide.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Martial Status*
Email*
example@example.com
If applying for a child does the child live with both parents? If no, please list name the non-custodial parent

HOUSEHOLD INCOME
What is your current monthly VA benefits award amount? This must match your summary of benefits award letter from the VA?*
What is the annual household income NOT including in your VA benefits (Must match last year's tax return)?*
How many people are in your household? These individuals must be listed on your Federal Tax Return.*
Number of Adults*
Number of Children*
Do you receive child support, alimony, social security or other income?*
If so, please explain

DENTAL INFORMATION
Is the applicant currently wearing braces?*
Does the applicant have primary Dentist?*
Dentist Name?*
Please list any health concerns for applicant that we should be aware of:*
Do you have orthodontic insurance?*
Has anyone in your family ever applied to Embracing Our Warriors for treatment?*
If so, please list the name
Why do you or your child want braces?*
Form of transportation to appointments*

GENERAL
How did you hear about us?*
I give permission to share my application and requested documents with the orthodontist who may be donating services through the Embracing Our Warriors program.*
I acknowledge that there are no guarantees regarding the availability of an orthodontist or that I will receive a Smile Service Award. I understand that should my child or I require urgent treatment, it is advisable to consult with an orthodontist privately. They may offer payment plans tailored to fit within my budget.*
I understand that EOW may share my story on the EOW website to raise awareness about the program, but will never use my real name or photo without my written permission.*

Yes, I understandNo, do not share my story
I have reviewed the household income guidlines on the EOW website to see if I qualify. I understand the $25 application fee is non-refundable.*
Application Fee*
prevnext( X )
Application FeeNon-refundable
$25.00 Quantity

Total

$0.00
Should be Empty:

EMBRACING OUR WARRIORS

MILITARY SERVICE INFORMATION

APPLICANT NEEDING ORTHODONTIC TREATMENT

HOUSEHOLD INCOME

DENTAL INFORMATION

GENERAL