Orthodontic Scholarship Application

You must submit TWO 5 x 7 photos of the applicant. One photo should be a headshot showing a full smile and the other should show only the applicant’s teeth.
You must have TWO letters of reference from school counselor, teacher, scout leader, coach, clergy or other non-family mentor (typed).

Applicant’s Name

DOB

Grade

School

Name of Parent/Guardian

Relationship

Address

Home Phone

Cell Phone

Parent/Guardian Employer

Is the Applicant covered by Dental Insurance?

Yes

Annual Household Income

Please be prepared to show a copy of last year’s tax return, W-2’s, or a copy of recent pay stubs for all family wage earners

Submitted by

Self

Parent

Educator

Dentist

other

Email address of Submitter

Phone

The Applicant is an excellent candidate for A Smile for Your Life Orthodontic Scholarship because

Application for Orthodontic Scholarship Questionnaire

Tell us about yourself. What are your interests and hobbies? What extracurricular activities are you involved with? Do you participate in any community service or volunteer projects? What are your goals for the future?

Why do you want braces? How do you feel about your smile now? How do you think braces could improve your life now and in the future?

If you had a chance to help others, would you? If so, list ways you would like to assist others?

Wearing braces on your teeth requires EXCELLENT brushing and home care, including brushing 3 times per day and using a Water Pik daily. How willing are you to put the extra effort in caring for your teeth while going through orthodontics?

Upload Files

Please upload any pictures, reference letters or supporting documents. Candidates chosen for screening will be asked to provide verification of family income.

***Services are 100% donated by Get-It-Straight Orthodontics***

**No reimbursement is received from Get It Straight Gives Foundation**

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Orthodontic Scholarship Application

Application for Orthodontic Scholarship Questionnaire