Flagstaff 7 – 18 | Smiles Change Lives

First Name *

Last Name *

Email *

What is your household size? *

2
3
4
5
6
More than 6

What is is your household taxable income? *

$48,720 or less
$48,721 - $61,260
$61,261 - $73,800
$73,801 - $86,340
$86,340 - $98,880
More than $98,880