Wally’s Kids Application Form

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
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
Dental Insurance Information
Does the applicant have private insurance?
Insurance Company
Subscriber Name
Subscriber Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
Preferred Location
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?
Financial Information
Privacy Statement

Information submitted through the Wally’s Kids Scholarship Application will be used solely to evaluate the applicant’s eligibility and financial and orthodontic need for the Wally’s Kids Scholarship Program.

Information may be reviewed by authorized leadership and members of the Wally’s Kids scholarship selection committee. We will only request additional information when reasonably necessary to evaluate the application.

Financial information, including any tax return or other income documentation requested, will be treated as confidential and will not be used for marketing purposes or shared with third parties except as necessary to administer the scholarship program, comply with legal obligations, or as otherwise authorized by the applicant or parent/legal guardian.

We take reasonable steps to protect information submitted through this application and limit access to individuals who need the information to administer or evaluate the Wally’s Kids Scholarship Program.

By submitting this application, the applicant’s parent or legal guardian acknowledges and agrees to the collection and use of the information described above for purposes of evaluating the Wally’s Kids Scholarship application.

For questions regarding the use of information submitted through this application, please contact us at info@w2ortho.com.
Household Size
Annual Household Income
Number of Dependents
Additional Financial Circumstances
Financial Documentation

Additional documentation may be requested if needed to further evaluate financial need. This may include a recent federal tax return, W-2, pay stub, or other appropriate income verification.

If additional documentation is needed, we will contact the applicant’s parent or legal guardian directly with instructions for securely providing the requested information.
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

Financial Information