Straighten Up Application

Recommender's Name*

First NameLast Name

Recommender's Email*

example@example.com

Student Name*

First NameLast Name

Student Date of Birth*

Date

Which school does the student attend?*

What grade is the student currently in?*

For the questions below, please have the student answer in their own words. They may answer in any language.

Please tell us why you would like to get braces, and how you think it will impact your life. *

Below are some of the reasons that people get braces. Think about how each reason applies to you and select the answer that best fits how you feel.

I am embarrassed of how my teeth look.*

Not at allA littleA lot

I have difficulty eating and/or drinking*

Not at allA littleA lot

I have pain in my mouth and/or jaw.*

Not at allA littleA lot

I have difficulty talking.*

Not at allA littleA lot

I cover my mouth when I talk or smile.*

Not at allA littleA lot

Do you wear braces or a retainer now?*

BracesRetainerNeither

Name of Parent/Guardian*

First NameLast Name

Parent/Guardian Email Address*

example@example.com

Mailing Address*

Mailing Address

Optional- Apartment, suite, etc.

CityState / Province

Postal / Zip Code

Cell Phone*

Please enter a valid phone number.

Home Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Relationship to applicant:*

Spouse's / Partner's Name (if applicable)

First NameLast Name

Are you aware of any obstacles (health problem, transportation issues, etc) that would impact this child's ability to complete the Straighten Up program?*

Do you give permission for your child's photo to be taken and used to promote this program within the community? This may include printed reports, newsletters, social media stories, newspaper articles, or other media? Your answer to this question will not impact your eligibility. Note: Our goal in sharing pictures of Straighten Up participants is to celebrate their new smiles, help other students in need learn about the program, and help engage community donors in support of the program.*

YesNo

Would you allow your child to share their experiences with the community to better educate groups and organizations on the importance of the Straighten Up program? Your answer to this question will not impact your child's eligibility for the program.*

YesNo

How many people live in your household?*

What is your total family income per year (from all sources)?*

For non-parental guardians, please upload a copy of your medical authorization for this child.

For children in state custody, please upload a copy of their state medical card and medical consent form.

Is this child covered by dental insurance (other than Medicaid)?*

YesNo

Please upload a dental referral form from the child's regular dentist.*

Your dentist should have this form available and will provide it upon request.

Please check "yes" if this student would like to auto-enroll in Feeding the Whole if this application is approved. Note- checking the box gives the Fund for Public Education permission to notify TCSD's Food Service Director that this student is enrolled in another FPE program.

Yes, please auto-enroll this student in Feeding the Whole if they are approved for this request.No, thank you.

Terms of the Program

By signing below, you acknowledge that you have read and agree to abide by all the following terms:

1) Straighten Up provides orthodontic treatment ONLY. Any additional treatments (such as extractions, cleanings, oral surgery, etc.) that may be necessary before, during, or after orthodontic treatment are the financial responsibility of the participant's parent(s) or legal guardian(s).

2) If the child has cavities or periodontal disease, these conditions must be completely remedied before orthodontic treatment starts.

3) During the course of orthodontic treatment, cavities may form around the braces if the child's teeth are not cleaned properly. If the child does not practice proper dental hygiene the orthodontist may remove the braces and end treatment. The child will then be dismissed from the Straighten Up program.

4) Treatment is only available through orthodontists who participate in the Straighten Up program.

5) Regular visit to the orthodontist are required to make sure that treatment is occurring properly. It is your responsibility to ensure that the child attends all scheduled appointments. Failure to meet this obligation is grounds for the orthodontist to remove the braces and end treatment. The child will then be dismissed from the Straighten Up program.

6) You and the child must follow the treatment plan set by the orthodontist, which will be explained to you before treatment starts. If you fail to follow the treatment plan, the orthodontist may remove the braces and end treatment. The child will then be dismissed from the Straighten Up program.

7) Broken appliances or loose brackets and bands can cause damage to teeth and the rest of the mouth. The child must take special care not to eat hard candy or sticky foods, or to pull on the braces. If there is frequent damage to the braces, the orthodontist may remove the braces or charge you to repair the damage. Damage sustained due to improper care is the responsibility of the child's parent(s) or guardian(s).

8) Children who have been dismissed from the Straighten Up Program for violating any of the above terms are not eligible to reapply.

9) Payment for treatment is made directly to the orthodontist.

10) If you have any questions, please contact the Fund for Public Education (307) 7432-9414.

Hold Harmless Agreement

By signing below, you also agree that you have read and consent to the following:

The Straighten Up program supplies funding for orthodontic care, not treatment. All treatment will be provided by an assigned orthodontist. The Straighten Up program, the Fund for Public Education, and/or Teton County School District #1 is not liable for any claims, demands, actions, or proceedings relating to this treatment or its outcome. If any portion of this agreement is held invalid, the remainder of it shall remain in effect.

Signature of Parent/Guardian*

Straighten Up Application

Student Information

PARENT/GUARDIAN INFORMATION

Financial Information

Pay-It-Forward Promise