English Application Email Head of Household/ Name of Father: Name of Mother or Other: Address: City: State Zip Code Home Phone Cell Phone Work Phone Total # of Family Members Total # of people living at your house Total # of people over the age of 18 Is/Are your child(ren) currentry a Kids in Need of Dentistry (KIND) Patient yes no Do any of the children currently have private insurance? yes no If yes, please list name of insurance Children Applying for Kids in Need of Dentistry Program Child's Name Birth Date Gender M F Child's Name Birth Date Gender M F Childs Name Birth Date Gender M F Child's Name Birth Date Gender M F Please Select one of the following and provide ID # if it applies CHP+ Medicaid WIC No Insurance Medicaid or CHP+ ID Number If your child has Medicaid, CHP+ or WiC you must upload the following Documentation: Copy of Medicaid Card, Copy of CHP+ Card, Copy of WIC Card and/or Letter, Copy of Section 8 Housing Benefits Letter If your child does not have any of the above assistance you must provide PROOF OF INCOME FOR EVERY WORKING ADULT IN THE HOUSEHOLD, by sending the documents required as follows: You are also required to return this application with proof of additional income if you receive any of the following: I certify that I have read and understand the above information to the best of my knowledge; the above questions have been answered accurately. I understand that providing false or incorrect information on this form or the supportive documents may cause dismissal of family members from the Kids in Need of Dentistry Program(s). I Accept Name Date Send
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