Beyond the Horizon — Podcast Guest Application
Share your story, dental needs, and application materials for consideration as a podcast guest—this does not guarantee selection, donations, or treatment.
About You
First name
*
Last name
*
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Telephone
*
Please enter a valid phone number.
Format: (000) 000-0000.
City
*
State/region
*
Preferred contact method
*
Email
Phone
Text
Travel availability to Gilbert, Arizona
*
Yes
No
Need help or more information
Yes - I live in Arizona
Acknowledgment
*
I am 18 or older
I understand if selected, I will be sharing my story on the podcast to help raise funds for my dental treatment.
Tell us about yourself
*
Story and Dental Needs
How have dental issues affected you?
*
What would receiving dental care mean to you?
*
What barriers have prevented you from getting care?
*
Have you been to a dentist in the last 5 years?
Yes
No
Do you have a treatment plan from a dentist visit within 1 year?
*
Yes
No
Unsure
What treatment has a dentist told you that you needed?
Example: Need teeth pulled and implants placed
Topics you prefer not to discuss publicly
Smile Photos
Photo guidance
Front-facing natural smile photo
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Closer view of teeth or dental concern
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Additional photo 1
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Additional photo 2
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Additional photo 3
Upload a File
Drag and drop files here
Choose a file
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of
Financial Circumstances
Household size
*
Approximate annual household income before taxes (USD)
*
Income sources
*
Employment
Self-employment
Benefits
Retirement
Family support
No income
Dental insurance
*
None
Does not cover needed care
Covers part
Unsure
Income verification method
*
Recent pay stubs
Relevant tax-return income pages only
Benefits/unemployment/retirement statement
Self-employment income summary
Other income documentation
No current income or unable to provide documents
If you have no current income or cannot provide documents, explain your situation
Upload income verification files (up to 3 files; PDF or supported image files, 10 MB each)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Further financial context
Review and Consent
Review your application summary below. Please go back and edit any section if needed before continuing.
Acknowledgment: The information I have provided is accurate to the best of my knowledge.
*
Acknowledgment: I give permission for the review team to review my application, photos, and income verification, and to contact me about this application.
*
Acknowledgment: if selected, I understand I may discuss agreed parts of my story publicly, but separate recording, publication, or fundraising consent is still required. This application is not a media release.
*
Acknowledgment: I understand there is no guarantee of selection, funding, or treatment, and any supporting documents should have sensitive identification and account numbers covered.
*
Submit application
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