Application checklist



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APPLICATION CHECKLIST




Application – Completed, as directed in black ink




Dental Referral Form




Contract – Read and signed by parent(s) and applicant




Report Card




Applicant Questionnaire – Handwritten by the applicant










Household Information – Complete and accurate










2 Letters Of Recommendation – Letters from at least two community leaders or teachers, with contact information attached




2 Photos – Close up photos of applicant’s teeth while smiling. (1) photo, teeth showing from the front and (1) photo of the teeth from the side.

IT IS YOUR RESPONSIBILITY TO ENSURE ALL DOCUMENTS ARE INCLUDED. WE WILL NOT NOTIFY YOU IF YOUR PACKET IS INCOMPLETE!

ORTHODONTIC SCHOLARSHIP

Smile for a Lifetime (S4L) is an international program that provides orthodontic scholarships (free braces) to children ages 11-17 who normally would not be

able to afford treatment. Dr. Mattiacio has formed a local chapter to serve children in Farmington, NY. There is no cost to those chosen

to receive an S4L orthodontic scholarship.




Scholars are chosen by a local board of directors and the process is competitive. Scholarships are limited and based on financial need, orthodontic need, and

a complete and accurate application.

QUALIFICATIONS

  • Family income of no more than (185%) of the federal poverty level. (Income eligibility form attached)*

If Chosen, proof of income will be required to verify eligibility prior to treatment. W-2, Income tax return, SSI award letter, TANF grant letter etc.

  • Applicant must be between the ages of 11 – 18.

  • Have “good” dental hygiene practices and had a dental hygiene check-up in the past 6 months.

  • Must have a functional and/or aesthetic need for braces.

  • Must currently be enrolled in school.

  • Must demonstrate a positive attitude.

  • Must follow and abide by treatment plan set forth by the orthodontist and contract attached.

  • Should demonstrate a willingness to get involved in the community through extracurricular activities and/or volunteer service.

  • Must have positive letters of recommendation from at least two community leaders and/or teachers.

* Chapter may consider exceptions under the “special circumstances” clause. Please speak with an S4L representative for more information

NOTE: If awarded, Proof of income is required prior to treatment. i.e. W-2, Income Tax Return for previous year, SSI Award Letter, Child Support, TANF grant letter, etc.

APPROVAL PROCESS

  • The screening committee for the Mattiacio Orthodontics of Smile for a Lifetime will select applicants on an ongoing basis.



  • Selection is based on the information provided within this packet (i.e. commentary, personal essay, character, and accompanying letters of recommendation),

orthodontic and financial need.




  • Please ensure that the packet is filled out completely and accurately. Incomplete packets will not be submitted to review board for selection process.




  • If you would like to reapply, please speak with an S4L representative for further information.



ORTHODONTIC SCHOLARSHIP APPLICATION FORM

Today’s Date:

Primary Dentist:

APPLICANT INFORMATION


Applicant’s Last Name:




First:




Middle:




Applicant’s Date Of Birth (MM/DD/YYYY):



Applicant’s Age:



Applicant’s Gender:

MALE

FEMALE

Are you currently enrolled in school:

YES

NO

What grade are you in :



What is your GPA:




Name of School:

Address (City, State, Zip Code):

Phone Number:

( )







Fax:

( )

Are you wearing braces?

If you are over the age of 16, what are your plans over the next 3 years (Moving, College, etc.):




Home Address:

City:

State:

Zip:

Home phone no.:

Cell phone no.:













( )

( )

How did you hear about Smile for a Lifetime (please circle or write in your answer)?

Internet Search

Family

Friend

Dentist/Orthodontist

Boys & Girls Club

State Office

Other:

(Please Specify)

Television

Magazine

Radio

Newspaper

CASA

Internet Ad




Are you a member of any of the following organizations? Circle all that apply:

BBBS

BGCA

CASA

NCOHF




There are many reasons why people get braces; please select the following that apply or feel free to add your own:




Discomfort while eating/drinking




Jaw and/or mouth pain




I look down when talking




Speech Impediment




I get teased about my teeth




I cover my mouth when I laugh




It’s hard to clean my teeth well




I’m embarrassed to smile




I have a hard time sleeping/Sleep apnea

GUARDIAN INFORMATION

Guardian’s Name:

Guardian’s Occupation:

Guardian’s Employer:

Employer phone no.:










( )

Guardian’s Name:

Guardian’s Occupation:

Guardian’s Employer:

Employer phone no.:










( )

Have any other children in the household been treated through Smile for A Lifetime (If so, whom)?




Please explain in detail why you would like your son or daughter to be awarded an orthodontic scholarship through Smile for a Lifetime.































What is the best way to reach you?:



Phone: ( )



Email:

APPLICANT QUESTIONNAIRE

HANDWRITTEN BY THE APPLICANT ONLY. Each question must be answered in essay format 5 to 7 sentences in length.*

Tell us about yourself. What do you like to do? Favorite hobbies, extracurricular activities, and the types of goals and aspirations in life. etc.











































Tell us about your family. How many siblings do you have, who are they, do they live with you, what do you like to do together? etc.








































Please tell us, in detail, why you would like braces and/or orthodontic treatment and how will orthodontia change your life? Etc.








































If you had a chance to do a favor for another person/organization, without any expectation of being paid back, what would you do and why?











































*If the minimum requirements are not met, your application will be considered incomplete and not included in selection process.

CONTRACT

If selected from the pool of applicants by the screening committee of Smile for a Lifetime Mattiacio Orthodontics to receive orthodontic

treatment, there are a few guidelines required for treatment. Throughout the selection process there is some professional guidance provided, if requested, but the

decision is largely subjective and based on the completeness of the application, commentary, personal essay, character and the accompanying letters of reccomenda-

tion submitted with your packet. Orthodontic treatment for Mattiacio Orthodontics Chapter of Smile for a Lifetime will be provided by Dr. Mattiacio and the

team in his office .

By submitting and signing this application you understand and agree to the following:

  1. I agree that appointments will be at the discretion Dr. Mattiacio and his team.

  1. I understand that this can mean scheduling appointments during non-peak hours.

  1. I acknowledge that appointments must be kept in order to achieve an expeditious and desirable result.

  1. I also understand that keeping appointments is essential to treatment success and is a requirement of accepting care from Dr. Mattiacio.

  1. If you must reschedule appointments, give the practice at least 24 hours’ notice. If more than two appointments are missed or appointments are

constantly rescheduled it will be considered out of compliance which is grounds for removal of braces and revocation of scholarship.

6) If you must relocate prior to the conclusion of treatment, Smile for a Lifetime will do its best to find another service provider. However, it is not

guaranteed that Smile for a Lifetime will have another provider available in the area and/or can continue to provide treatment as a result.

  1. One retainer will be provided as a part of the scholarship award, any replacements will not be covered by or Smile for a Lifetime or Mattiacio Orthodontics

Chapter of Smile for a Lifetime.

  1. Direct responsibilities of the patient:

  1. Maintain excellent oral hygiene (tooth brushing, flossing). If unwilling to meet expectations due to medical and dental health risks, treatment will be discontinued.

  1. Follow the rules for eating habits. This will greatly reduce breakage of appliances (i.e. braces) and it is necessary for satisfactory completion of treatment.

  1. Cooperate. More than two (2) loose brackets may be deemed sufficient evidence that cooperation is not sufficient to meet minimal requirements for treatment.

d) Other cooperation issues are with failure to cooperate with maintenance of auxiliaries including elastics, wearing head gear, and springs.

  1. Attitude. You will be expected to maintain an exceptionally appreciative and respectful attitude once accepted into orthodontic treatment or any other aspect of treatment

supported by Dr. Mattiacio or Smile for a Lifetime. Rude behavior or an inappreciative attitude is unacceptable.

  1. ATTENTION: Failure to fulfill your responsibilities may result in removal of orthodontic equipment and discontinuation of treatment

Applicant Initials: _______________

  1. ATTENTION: Honesty is expected. Any misrepresentation, falsification or exclusion of income will be grounds for dismissal from the program. Future applications



will not be considered. There are many deserving children who are in need of orthodontics, we are here to serve those in greatest need.

Guardian’s Initials: _______________

  1. Media Disclaimer: If your child is the chosen applicant, you consent to Smile for a Lifetime’s (S4L) use, without charge, of all photos, video and audio recordings of your child. S4L may,

  1. Copyright, broadcast, display, publish, re-publish and reproduce your child’s image, voice and any statements made by him/her, in whole or in part, in any and all media forms; and

  1. Assign your child a fictitious name or use his/her first name, likeness, video, photograph, voice, statements and biographic or other information concerning his/her participation with

S4L for fundraising or other promotional and advertising purposes. You and your child also agree to participate in surveys and case management during and after receiving treatment.



Legal Guardian Consent: I certify that I am the legal guardian of the child listed on this application. I have all rights and authority to make medical decisions for the child, that all information

in this application is true and correct.

This scholarship is intended specifically for underserved and deserving children in the community. There are many children who need and deserve an

award winning smile and while we do our best to serve those greatest in need, it is a competitive process and not everyone will receive a scholarship.

Please take your time on your application; your time and effort will be taken into consideration when selecting applicants for scholarships.





















Applicant’s Name (Printed First, MI, Last)



Applicant’s Signature



Date











Guardian’s Name (Printed First, MI, Last)



Guardian’s Signature



Date











Guardian’s Name (Printed First, MI, Last)



Guardian’s Signature



Date





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