Apply for Braces - Jones Foundation



The Jones Foundation supports youth residing only in Coffey, Lyon and Osage counties in the state of Kansas. If you do not reside in these counties you may qualify for Smiles Change Lives, please visit www.smileschangelives.org/apply.


The Walter S. and Evan C. Jones Foundation has contracted with Smiles Change Lives (SCL) to administer their orthodontic program serving youth in Coffey, Lyon and Osage counties in Kansas. SCL is responsible for managing the day-to-day program operations, responding to applicant inquiries, approving requests and coordinating case management throughout the entire orthodontic treatment process.

Smiles Change Lives and its orthodontic providers are dedicated to providing braces for youth from low-income families. We believe self-esteem and confidence are very important to the development of a child. SCL orthodontic providers offer quality treatment and healthy smiles to the most qualified and deserving kids.

     


QUALIFICATIONS:


  • Be up to, but not including, 19 years of age;
  • Have good dental hygiene (as certified by the child’s general dentist within 30 days of application date);
  • Have no unfilled cavities;
  • Have a moderate to severe need for braces;
  • Not be wearing braces currently; nor ever have received braces from the Jones Foundation previously;
  • Have a total household income at or below 200% of the Federal Poverty Level
    This can be determined by visiting http://www.smileschangelives.org/financial
  • Be a US citizen (proof of US citizenship MUST be included) who has resided in Coffey, Lyon, or Osage counties in Kansas continuously for the past 12 months and will continue to reside in one of these counties for the entire term of treatment and;
  • If approved, be willing to pay the $30 (USD) application fee and the $600 (USD) program administration fee (per child).

APPLICATION INSTRUCTIONS:


  1. Click “Download Application”
  2. Print the application
  3. Fully complete all required portions of the application
  4. Mail the completed application, along with all additional required documents to:

    Smiles Change Lives/Jones Foundation
    2405 Grand Blvd, Suite 300
    Kansas City, MO 64108

    Please ensure you use adequate postage and keep a copy of the entire application for your records.



If you do NOT live in Coffey, Lyon or Osage counties in Kansas, you cannot apply using this application. Instead, please visit www.smileschangelives.org/apply for the correct application.

You must have Adobe Reader to download the application. Download Adobe Reader here.



APPLICATION CHECKLIST:


In order to be considered for the SCL program, all of the items below must be fully completed and submitted to SCL for each
child that is applying to the program. Please use the checklist below to ensure you’ve included each of the required documents; that each has
been fully completed; and that all items are signed where required.

Because the needs for assistance goes beyond our ability to ensure treatment for every applicant, the SCL acceptance policies are very strict. If your application is incomplete in any way, it will be rejected and returned to you. If you wish to reapply you will be required to submit a new application with an additional $30 application fee.


□  $30.00 non-refundable application fee (personal check, cashier’s check or money order; made payable to Smiles Change Lives)

□  Child’s Application (pg. 3)

□  Parent/Guardian Application (pg. 4)

□   Notice of Privacy Practices (pg. 5 - Must be signed by parent/guardian)

□   Program Rules and Guidelines (pg. 6 - All items MUST be initialed by parent/guardian)

□  Parent/Legal Guardian Consent & Child Consent (pg. 7 – Must be signed by BOTH parent/guardian & child)

□  Dental Referral Form (pgs. 9-10 – Must be completed by the child's general dentist or dental hygienist based on an examination no more than six (6) months prior to the application date. Must show good dental hygiene and no unfilled cavities)

□  Federal Tax Form 1040/1040A/SSI Awards letter - Proof of income MUST be submitted in the form of either a COMPLETE copy of the most recent tax year's federal tax return (include ALL pages, schedules, statements) AND/OR a copy of a current SSI awards letter. Tax forms/SSI awards letters that are altered in any way, including removing/blacking out Social Security numers, will NOT be accepted. If you are submitting applications for more than one child, you MUST include a copy of your tax return/SSI awards letter with EACH application.  

If submitting Form 1040/1040A, please note:

    • The child applying for treatment MUST be listed as a dependent on either page 1 of Form 1040/1040A or on Statement 1 along with the child's Social Security number.
    • If the child is NOT claimed as a dependent on your tax return, you must explain why and ALSO submit the tax return for the person who DOES claim the child, as well as proof of where the child resides (e.g. school records). In this situation, both tax returns must meet our income qualifications.
    • Page 2 of Form 1040/1040A (line 43 on 1040 and line 27 on 1040A) must show total household income at or below 200% of the Federal Poverty Level.
    • If your income does not require you to file taxes, but you are legally allowed to file, you must do so in order to apply for our program, even if your income is $0.

□ Optional: Personal essay from the applicant and/or letters of support detailing why the applicant wants braces, how they feel their life might be improved as a result of treatment, etc. (This is optional but encouraged)

*** Additional documentation for non-parental guardians

□ Non-parental guardians must also submit a copy of their authorization to make medical decisions.

□ For children in state custody, copies of the child's state medical card and medical consent must also be submitted.

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Smiles Change Lives

2405 Grand Blvd. Suite 300, Kansas City, MO 64108
Phone: 816.421.4949 | Fax: 816.421.3008
info@smileschangelives.org

The Virginia Brown Community Orthodontic Partnership

Copyright © 2013 Smiles Change Lives, All Rights Reserved