Student's Full Name *

Student's Phone *

Guardian Full Name

Guardian Email

Guardian Phone

How did you hear about us? *

Current School Year? *

What School are you enrolled in? *

Do you currently have dental insurance, if so with who? *

If none type None

Student, write a short paragraph WHY we should select you and about how you will benefit from having your wisdom teeth removed:

I understand that if I am selected for the sponsorship, I will be giving permission for MEDIA RELEASE and AUTHORIZATION FOR DISCLOSURE AND PUBLICATION OF HEALTH INFORMATION-HIPAA

Student Signature *

Guardian Signature