School Application

School & Program Onboarding Form
Welcome to the Healthy Smiles school onboarding form.

Please complete the information below so we can begin the onboarding process for your school or program.

This form should only take a few minutes to complete.
What type of program are you?
School or Program Name
District or Organization
If not applicable, you may leave this blank.
Is your school or program located in NYC?
Primary Contact Name
Principal, Director, or Program Lead
Primary Contact Role/Title
Example: Assistant Principal, Office Manager, Parent Coordinator
Primary Contact Email
example@example.com
Primary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is there someone else we should coordinate with?
Additional Contact Name
Additional Contact Role/Title
Example: Assistant Principal, Office Manager, Parent Coordinator
Additional Contact Email
example@example.com
Additional Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
School or Program Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Grades or Age Groups Served
Example: K–5 or 3K / 4K
Approximate Total Enrollments
Where would we likely set up?
Approximate Room Size
Example: 35 ft x 65 ft. A rough estimate is fine.
Upload a photo or quick sketch of the space

Cancelof
Confirmation
We’ll take care of all NYS required paperwork on our end.
Number of schools or programs involved
Preferred start date for onboarding

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you have any special accommodations or accessibility needs?
Authorized Signature
Should be Empty:

School & Program Onboarding Form