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, 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.
MILITARY SERVICE INFORMATION
Name of Member who served in the military
*
First Name
Last Name
Do you have a service related disability?
*
Please Select
Yes
No
Which branch of the military did you serve?
*
What inspired you to seek orthodontic treatment?
*
Please explain
In what ways do you think straightening your teeth will improve your life?
*
Please explain
Are you experiencing any form of financial hardship
*
Please explain
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APPLICANT NEEDING ORTHODONTIC TREATMENT
Name of Applicant Receiving Orthodontic Treatment
*
Applicant's relationship to Service Member
*
Please Select
Self
Spouse
Child
Age of person receiving Treatment
*
Date of Birth of person receiving treatment
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
If applying for your child, please include parent's name
First Name
Last Name
If your address is different then the child, please provide.
*
Street Address
Street Address Line 2
City
State / 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
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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?
*
Number of Adults
*
Number of Children
*
Do you receive child support, alimony or social security?
*
If so, please explain
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DENTAL INFORMATION
Does the applicant have primary Dentist?
*
Please Select
Yes
No
Dentist Name?
*
Please list any health concerns for applicant that we should be aware of:
*
Form of transportation to appointments
*
Do you have orthodontic insurance?
*
Please Select
Yes
No
Has anyone in your family ever applied to Embracing Our Warriors for treatment?
*
If so, please list the name
Is the applicant currently wearing braces?
*
Please Select
Yes
No
Why do you or your child want braces?
*
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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.
*
Please Select
Yes, I give permission
No, do not share my information
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.
*
Please Select
I acknowledge and want to continue with my application.
Submit
Submit
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