Name Description Weighting Release Date Categories Scholarship :::::::::: TLC 3.0 :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Patient Full Name Date of Birth Gender male female other Address City State Zip Code School Attending Grade Image :::::::::: Parent/Family Info :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Parent First Name Parent Middle Name Parent Last Name Parent Phone Parent Phone Alt Parent Email Parent Address Parent City Parent State Parent Zip Code Relationship To Child Parent Marital Status single married separated divorced widowed Partners Name Non Custodial Parent :::::::::: Parent Financial Info :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Parent Occupation Employer Hourly WageSalary Hours Per Week Gross Income Per Month Number People In Household Number of Adults Number Of Children :::::::::: Other Sources Of Income :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Income1 Source Income1 Amount Income2 Source Income2 Amount Income3 Source Income3 Amount Income4 Source Income4 Amount :::::::::: Dental Info :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Dental Insurance yes no Dental Insurance Name General Dentist Last Dental Cleaning Dental Work Completed yes no :::::::::: Additional Info :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Child Transportation Any Family Member Treated yes no Name of Child :::::::::: Reason For Scholarship Request :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Short Essay :::::::::: Community Service :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Short Essay Community :::::::::: Application Photos :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: photo1 photo2 photo3 photo4 photo5 photo6 photo7 photo8 :::::::::: Letters Of Recommendation :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Letter1 Letter2 :::::::::: Report Cards :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Report Card1 Report Card2 :::::::::: Program Rules And Guidelines :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: Understand Rules And Guidelines Yes Acknowledge Rules Guidelines