Eternal Smiles Foundation Grant Application Pre-Screen

Eternal Smiles Foundation Grant Application Pre-Screen

Complete this form to determine if you are an eligible grant applicant.
Parent/Guardian Name*

First NameLast Name
Email Address*
example@example.com
YesNo
Based on the information submitted, you are currently ineligible for this program at this time.
YesNo
Based on the information submitted, you are currently ineligible for this program at this time.
YesNo
Based on the information submitted, you are currently ineligible for this program at this time.
YesNo
YesNo
Based on the information submitted, you are currently ineligible for this program at this time.
YesNo
Based on the information submitted, you are currently ineligible for this program at this time.
YesNo
HHS Poverty Guidelines for 2026
Based on the information submitted, you are currently ineligible for this program at this time.
YesNo
Based on the information submitted, you are currently ineligible for this program at this time.
YesNo
Based on the information submitted, you are currently ineligible for this program at this time.
YesNo
Based on the information submitted, you are currently ineligible for this program at this time.
YesNo
Only one child per family may receive an Eternal Smiles orthodontic grant within a single calendar year. Additional children in the same household are not eligible until the next grant year.
YesNo
Based on the information submitted, you are currently ineligible for this program at this time.
YesNo
Based on the information submitted, you are currently ineligible for this program at this time.
YesNo
Based on the information submitted, you are currently ineligible for this program at this time.
YesNo
Based on the information submitted, you are currently ineligible for this program at this time.
YesNo
Based on the information submitted, you are currently ineligible for this program at this time.
Should be Empty: