Nominate

Who is eligible?
Any person 28 years or younger who can show a financial need and is in need of orthodontic treatment may apply.

The Application
An applicant must first be nominated by an educational professional such as a teacher, counselor, administrator, or by an employer or health care professional. An application will then be forwarded to the individual from the organization via email or US Postal service.

Download
Nomination Form

Your Information

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Relationship to Nominee *

Business Education Medical

Address *

Line 1

Line 2

City

State

Zip Code

Country

Where do you work? *

Job Description *

Nominee Information

Name *

First

Last

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Comments- Please tell us as much as you can.

What makes your nominee a good fit for this program? *

How long have you known this individual? *

How is this person deserving of braces? *

Tell us how you feel orthodontic treatment may help this person improve his or her life. *

Nominate Now

Nominate

Special thanks to our supporter, Pitts Orthodontics