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SMILE CLUB APPLICATION FORM
CHILD INFORMATION
Date of birth
+
Gender
Male
Female
Other
Child's last name
Child's first name
Middle initial
School attending
Grade
Ethnicity
Hispanic
Non-Hispanic
Decline to specify
Race (select all that apply)
White
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
Decline to specify
Other
Other
Child's dental insurance
Forward Health/Medicaid/BadgerCare
Private Insurance (Carrier Name: i.e. Delta, Cigna)
None
Dental insurance member ID number (if known)
Does your child qualify for free or reduced rate meals at school?
Yes
No
Does your child have a dentist?
Yes
No
Dentist name
Date of last visit