New Application

Please complete the following application to be considered for an Orthodontic Scholarship from Meyer Dana Smile Foundation and Meyer Dana Orthodontics. You can save your progress at any point, and return to upload photos and complete the application at a later time.

Qualifications

Applicant Requirements

Between the ages of 11-19

Must live in the Black Hills area, within 50 miles of the Rapid City or Spearfish Meyer & Dana Orthodontics office

Must meet the financial guidelines

Have a functional/aesthetic need for braces

Dental Exam and cleaning within the last 6 months. Must maintain recommended dental cleanings during treatment

Good dental hygiene and no dental work that needs to be completed

You and your child must commit to the treatment plan set forth by the orthodontist

Application Process

Upon receipt of the COMPLETE application, the application will be reviewed by the Meyer Dana Smile Foundation. If your application is INCOMPLETE, you will be notified by email. In order to be considered the application will need to be completed and resubmitted.

Meyer Dana Smile Foundation is a nonprofit organization that was created to help individuals who are not able to afford orthodontic care, have the opportunity to get the smile they’ve always wanted.

Recipients are chosen by a local board of directors. The selection process is very competitive and recipients are chosen based on orthodontic need along with a complete, accurate application showing financial need and community service intentions.

Patient Info

Patient Full Name*

Name (Auto-change)

Gender

Male

Female

Other

Date of Birth

Address

City

State

Zip

School Attending

Grade

Parent/Guardian Info

Notice

For Non-Parental Guardians, you must submit a copy of your medical authorization.

First Name

Middle

Last Name

Phone

Phone Alternate

Email*

Address

City

State

Zip

Relationship To Child

Parent Marital Status

Single

Married

Separated

Divorced

Widowed

Partners Name

Non-Custodial Parent

Income Eligibility Guidelines

Family income no more than 185% of the federal poverty level.

Household Size	Federal Poverty Level	185% of Poverty Level	Monthly Gross Income
1	$15,060	$27,861	$2,321
2	$20,440	$37,814	$3,151
3	$25,820	$47,767	$3,980
4	$31,200	$57,720	$4,810
5	$36,580	$67,673	$5,639
6	$41,960	$77,626	$6,468
7	$47,340	$87,579	$7,298
8	$52,720	$97,532	$8,127

Updated 5/21/2024

Updates to federal poverty guidelines can be found at http://www.fns.usda.gov/cnd/governance/notices/iegs/iegs.htm

Financial Documents

Please mail/drop off your W-2 or income tax return from the previous year to 220 Ryan Road, Spearfish, SD 57783. (Paystubs are not acceptable)

Parent Financial Info

Parent Occupation

Employer

Hourly Wage/Salary

Hours Per Week

Gross Income Per Month

Number People In Household

Number of Adults

Number Of Children

Other Sources of Income

Please list any other Sources of Income including:
Child Support or Alimony, Unemployment, Lump Sum Payment (Lawsuit/Insurance, Settlement, Social Security, SSI, SSDI, Inheritance, Lottery, Other)

Other Income Source 1

Income1Amount

Other Income Source 2

Income2Amount

Other Income Source 3

Income3Amount

Other Income Source 4

Income4Amount

Dental Info

Dental Insurance

Yes

Dental Insurance Name

Dental Home

Last Dental Cleaning

Previous Dental Work Completed by Us

Yes

Additional Info

Any Family Member Previously Treated by Us

Yes

Name of Family Member

Transportation for Child

Patient Photo

Please upload a photo of patient.

Max 5mb

Short Essays

Reason for Scholarship Request

Please tell us, in detail, why you want/need orthodontics and how this will improve your life? Upload a file (.pdf, .jpg, .doc, etc) below.

Max 5mb

Community Service

The more we give, the happier we feel. Volunteering increases self-confidence. You are doing good for others and the community, which provides a natural sense of accomplishment. Each of us should be willing to offer our own time and expect nothing in return. If selected for Meyer Dana Smile Foundation orthodontic treatment, it is important that the recipient complete 10 hours of volunteer work for our local community while you are in treatment.

Tell us how you would volunteer your time in our local community if you were selected as a recipient of free orthodontic treatment from the Meyer Dana Smile Foundation? Upload a file (.pdf, .jpg, .doc, etc) below.

Max 5mb

Letters

Please provide two letters of recommendation. Letters should be from at least two community leaders or teachers with their contact information listed.

Recommendation 1

Max 5mb

Recommendation 2

Max 5mb

Report Cards

Please provide two year-end report cards from school- Attendance must be listed.

Report Card 1

Max 5mb

Report Card 2

Max 5mb

Photos

Please upload eight photos of your child (see attached examples), or deliver to our office.

See Example Photos

How To Take Photos

Example Photos

Posted Jan 1, 2019
Updated Sun, Jul 31, 2022 • 6:06 pm

Photo 1

Max 5mb

Photo 2

Max 5mb

Photo 3

Max 5mb

Photo 4

Max 5mb

Photo 5

Max 5mb

Photo 6

Max 5mb

Photo 7

Max 5mb

Photo 8

Max 5mb

Program Rules and Guidelines

Custodial Parent/Legal Guardian, or if 18 or older, please read carefully

Meyer Dana Smile Foundation provides orthodontic treatment only. Extractions, cleanings, oral surgery or any other dental treatment that may be necessary before, during, or after orthodontic treatment are not covered by Meyer Dana Smile Foundation.

Excellent Oral Hygiene is important and expected:
Poor oral hygiene (tooth brushing) may require termination of treatment due to potential medical and dental health risk.

Following Recommendations:
Patient must follow all of the recommendations of the orthodontist, which will be explained to you before treatment starts. If you fail to follow the treatment plan, including but not limited to: proper use of bands, appliances, and retainers the treatment provider has the option to refuse to continue treatment and to remove braces.

Nothing loose or broken:
Following rules for eating and habits will reduce breakage of appliances and help complete treatment on time. Excessive breakage may be deemed sufficient evidence that cooperation is not sufficient to meet minimal requirements for discontinuing of orthodontic treatment.

Positive Attitude:
Patients and family members will be expected to treat all staff of Meyer Dana Smile Foundation and Meyer Dana Orthodontics with respect at all times. If patient or Custodial Parent/Guardian at any time is uncooperative or disrespectful, treatment will be discontinued and braces will be removed.

Failure to show for appointments:
Regular appointments are required to help ensure treatment progresses as well as possible. Appointments will usually be scheduled between 8:30am and 2:30pm. It is your responsibility to make sure that all scheduled appointments are kept.

Acknowledgement of Rules and Guidelines

Yes