Wally’s Kids Application Form ES

Wally’s Kids Application Form

Please fill out your personal, dental, and insurance details, upload a photo, and consent to social media use.
Applicant Information
First Name
Middle Name
Last Name
Date of Birth

MonthDayYear
Date
Sex
Parent/Guardian Information
First Name
Middle Name
Last Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Textable Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Dental Information
General Dentist Name
Approximate Date of Last Dental Cleaning

MonthDayYear
Date
Dental Insurance Information
Does the applicant have private insurance?
Insurance Company
Subscriber Name
Subscriber Date of Birth

MonthDayYear
Date
Subscriber SSN
Relationship to Patient
Employer
ID Number
Group Number
Please include the following note:

Having dental insurance will not disqualify you from the Wally’s Kids Program. Please provide complete insurance information.
Medicaid / ProviderOne
If the patient has ProviderOne insurance through Washington State Medicaid (including AmeriGroup, Community Health Plan of Washington (CHPW), Coordinated Care, Molina, or United Healthcare Community Plan), please include:
Have you applied through the state for orthodontic treatment?
If yes, were you denied through the state?
Photo Upload and Consent
Please include an upload button for applicants to submit a photo showing a full smile with teeth visible.

Cancelof
Consent
Questionnaire
How did you hear about the Wally’s Kids Scholarship Program?
Tell us about yourself—your interests, hobbies, activities, and future goals
How do you feel about your smile?
How has your smile and/or bite impacted your life?
How would correcting your smile and/or bite benefit you?
Describe any financial barriers that may have prevented orthodontic treatment in the past
What are your plans after high school graduation?
Should be Empty:

Wally’s Kids Application Form

Applicant Information

Parent/Guardian Information

Dental Information

Dental Insurance Information

Medicaid / ProviderOne

Photo Upload and Consent

Questionnaire