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Smiles for Success
Participant Application


In order to qualify for the Smiles for Success program you have to:

  • Be currently enrolled in an accredited job-training program
  • Provide us with the number of your caseworker who can verify your status
  • Actively pursuing to transfer from public assistance into the workforce

    Volunteer Dentists are donating their time and expertise. Laboratory costs are reimbursed to volunteer dentists who are members of the American Association of Women Dentists (AAWD). Services provided are limited to certain procedures. Crowns and bridges, orthodontics, partial or full upper and lower dentures are not always covered except in certain cases in which laboratory expenses have been pre-approved by Smiles.

    Click here to download a Participant Application     or fill out the form below.

**PLEASE NOTE**

If you are currently employed, not enrolled in a job-training program and don't have a caseworker
you do not qualify and your application will not be reviewed.

For a list of training programs click here.

First Name
Last Name
Address 1
Address 2
City
State
Zip
Phone
E-mail
Age
Marital Status
Ethnicity
American Indian and Alaska Native/Asian/Black or African American/Native Hawaiian and Other Pacific Islander/ White/ Other
   
Have you previously received dental care through the Smiles for Success Program?
If yes, please let us know the name of the dentist and when you received treatment.
Job-Training Program Information
Job-Training Program:
Caseworker First Name:
Caseworker Last Name:
Phone:
Email:
Program Start Date:
Estimated Date of completion:
Referring Agency
If Referring Agency and Job-Training Program are the same, you may leave Referring Agency blank.
Referring Agency:
Caseworker First Name:
Caseworker Last Name:
Phone:
Email:
 
When did you last see a dentist?
What service did the dentist provide?
Describe you dental needs
All potential participants are pre-screened. Only certain procedures are covered by the Smiles for Success program. Examples of some procedures NOT covered are: bleaching or whitening of the teeth, braces and removal of wisdom teeth. In addition, following procedures are not covered unless laboratory expenses have been pre-approved by Smiles for Success: Crowns and bridges, Orthodontics, Partial upper and Partial lower dentures, full upper and full lower dentures.
How will you get to dental appointments?
What other towns could you travel to for treatment?
Towns should not be more than one hour away by car/public transportation.
The dentists in our program donate their time and services. They are not paid by the Smiles for Success Foundation. If you are accepted into this program, the dentist will help you restore your oral health. What plans do you have to ensure your oral health in the future?
 
Do you receive Medicaid or Medicare benefits? Medicare Medicaid
Do you have Dental Insurance?
If yes, please specify:
 
 
Smiles for Success Foundation
216 W. Jackson Blvd., Suite 625
Chicago, IL 60606
Phone: 800.920.2293
Fax: 312.750.1203
E-mail: info@smilesforsuccess.org