BSF-Application

The Blooming Smiles Foundation
Application
"A Confident Smile Can Change a Life"
Please complete this form as fully as possible. All information provided will remain strictly confidential and used solely by The Blooming Smiles Foundation to evaluate the child's eligibility for orthodontic care through our program.
Information
Name of child*
Childs Age*
School Name*
Nominator Name*
Relationship to child*
Phone*
Email*
example@example.com
Please check any that describe the child's confidence or self-consciousness
HE or SHE..

Avoids smiling or showing teethIs reluctant to participate in group photos or selfiesCovers mouth when speaking or laughingExpresses embarrassment or discomfort about their smileIs bullied or made fun ofOther
Dental Background
Has the student received orthodontic treatment in the past?
Has the child seen a dentist within the last year?
Has a dentist recommended orthodontic treatment?
Why do you believe this student is especially deserving of orthodontic treatment through The Blooming Smiles Foundation? (Please include details about their character, personal challenges, or perseverance.
Answer:
Has this student shown kindness, leadership, or resilience despite personal or financial hardships, and how might receiving orthodontic care change this students confidence or daily life?
Answer:
Please use the space below to share any other details that might help The Blooming Smiles Foundation better understand this student, their character, or any circumstances that could support their consideration for orthodontic care.
Answer:
Thank you for taking the time to nominate a deserving student - your insight helps The Blooming Smiles Foundation bring confidence and brighter futures to children in our community.
Signature*

Clear
Date

MonthDayYear
Date
Please submit a current photo of the child
Should be Empty:

Application

"A Confident Smile Can Change a Life"

Information

Dental Background