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?*

5 - The child's health and well being are severely impacted.4 - The child's health and well being are somewhat impacted.3 - The child's health and well being have the potential to be impacted if the problems are not addressed soon.2 - The child's health and well being are not impacted, but preventative care would be helpful.1 - The child's physical health and well being are not at risk, but there are cosmetic issues that impact the child's self-esteem.
How would you rate the urgency of this child's dental issues?*

Emergency care is needed.Routine care is needed.Preventative care is needed.
Tell us why you're recommending this child for treatment.*
Does this child currently have difficulty eating, drinking, or speaking?*

Not at allA littleA lot
Does this child currently report pain in their mouth or jaw?*

Not at allA littleA lot
Does this child currently wear braces or a retainer?*

BracesRetainerNeither
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.
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)?*

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.
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.

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

Powered by Jotform SignClear
Should be Empty:

Love Your Teeth Dental Program Application

Student Information

Student Dental Information

PARENT/GUARDIAN INFORMATION

Financial Information