Clone of Straighten Up Application

Love Your Teeth Dental Program Application
Recommender's Name

First NameLast Name
Recommender's Email
example@example.com
Student Information
Student Name

First NameLast Name
Student Date of Birth

MonthDayYear
Date
Which school does the student attend?
What grade is the student currently in?
Student Dental Information
How would you rate the severity of this child's dental issues?
How would you rate the urgency of this child's dental issues?
Tell us why you're recommending this child for treatment.
Does this child currently have difficulty eating, drinking, or speaking?
Does this child currently report pain in their mouth or jaw?
Does this child currently wear braces or a retainer?
Has this child been seen by a dentist recently? If so, please type their information below. Otherwise, respond N/A.
PARENT/GUARDIAN INFORMATION

We ask for your complete contact information so that the orthodontist can reach you to schedule appointments or to discuss your child's treatment. We never share your information with anyone other than the dentist's office.
Name of Parent/Guardian

First NameLast Name
Relationship to applicant:
Parent/Guardian Email Address
example@example.com
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Mailing Address

Optional- Apartment, suite, etc.

CityState / Province

Postal / Zip Code
Spouse's / Partner's Name (if applicable)

First NameLast Name
Spouse's / Partner's Contact Information (if applicable)
Financial Information

We collect financial and employment information only so that we can ensure that Straighten Up funds go to families with the greatest need. We will not share your information with anyone other than the orthodontist's office. We will never contact your employer without asking you first.
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.

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

Cancelof
Is this child covered by dental insurance (other than Medicaid)?
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.
Cancelof
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.
Hold Harmless Agreement

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

The Love Your Teeth program supplies funding for dental care, not treatment. All treatment will be provided by an assigned dentist. The Love Your Teeth 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
Should be Empty:

Love Your Teeth Dental Program Application

Student Information

Student Dental Information

PARENT/GUARDIAN INFORMATION

Financial Information