MCH-IOHI - Smiles for Life Stipend Form

Smiles for Life Stipend Form

Please complete this form if you are seeking the stipend for completing all of the Smiles for Life modules. After completing this form, you will receive a Docusign to the email provided below to complete an agreement and W-9. Stipends will be sent to the address you provide on your W-9 and may take 6-8 weeks to process.
Questions?

Please contact Danika Comey at danika.comey@montana.edu
Name*

First NameMiddle InitialLast Name
Organization *
Job Title/Role*
Certifications held (such as RN, Community Health Worker, etc.)
Phone Number*
Please enter a valid phone number.
E-mail*
example@example.com
Evaluation
Are you already performing oral health related activities or supporting oral health activities in your workplace?*

YesNo
If yes, please describe:
Will you use what you learned in the modules in your work?*

DefinitelyProbablyPossiblyProbably NotDefinitely Not
Training Option
Have you completed at least six of the Smiles for Life modules? To receive the stipend, you must complete a minimum of six modules.
Please documentation of all of your Smiles for Life certificates (minimum of six courses required):
File Upload*

Cancelof
Stipend Information

After the completion of this form, you will receive a Docusign to the email provided above to complete an agreement and a W-9. In order to provide stipends for eligible participants, we are required to collect the following information: W-9, mailing address, and signature. Reimbursement can be expected in the form of a check to the mailing address provided on your W-9 with approximetely 6-8 weeks processing time. Stipends are processed after the completion of courses.
Please confirm the address that your check will be mailed to:

This should match the address provided on your W-9
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Required Reporting Information

This stipend will be provided to you due to funding made available through the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). We are required to provide demographic information of all participants. All identifiable information will be removed and replaced with unique identification number and your identity will remain anonymous. Thank you for your participation!
Signature*

Clear
Notice

The Health Resources and Services Administration (HRSA), Department of Health and Human Services provided financial support for this project. The award provided 100% of total costs and totaled $425,000. The contents are those of the author. They may not reflect the policies of the Department of Health and Human Services or the U.S. government.
Should be Empty:

Smiles for Life Stipend Form

Questions?

Evaluation

Training Option

Please documentation of all of your Smiles for Life certificates (minimum of six courses required):

Stipend Information

Please confirm the address that your check will be mailed to:

Notice