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Harwell & Cook Orthodontics
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Smile for a Lifetime Foundation
Date of Birth
MM slash DD slash YYYY
Name of School
Name of Parent/Guardian
How long have you lived in this city
Is the Applicant covered by dental insurance?
Does Applicant qualify for government assistance
Annual Household Income (Please be prepared to show a copy of last year’s tax return, W-2s, or copies of recent pay stubs for all family wage earners.)
E-mail address for Submitter
The Applicant is an excellent candidate for a Smile for a Lifetime Orthodontic Scholarship because:
How did you hear about the foundation
Tell us about yourself. What are your interest and hobbies? What extracurricular activities are you involved with? Do you participate in any community service or volunteer projects? What are you goals for your future?
Tell us about your family. How many live with you, and who are they?
Why do you want braces? How do you feel about your smile now? How do you think braces could improve you life now and in the future?
If you had a chance to help others, how would you help them?
Have you seen a dentist before? If so, when?