Smile Kit Application Local
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Smile Kit Application Local

2017 Smile Kit Program Application

Organizations within Sedgwick County are required to pick up Smile Kit donations from a Wichita facility. If awarded kits, we'll be in touch with additional details.

Date*
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ORGANIZATION INFORMATION
Organization name*
Street address*
City*
State*
ZIP*
Contact name*
Title*
Phone number*
Email address (used for contact purposes)*
PROJECT INFORMATION
Project name*
Project purpose*
Does your project have an oral health education or outreach component? If yes, please explain.*
How will the kits be distributed? If in a school, which one(s)?*
Does your project target uninsured or underserved residents in Kansas? If yes, please explain.*
Project term in months*
Project start date*
Project end date*
Estimated number of direct lives affected annually (Children under 20)*
Estimated number of direct lives affected annually (Adults 20+)*
What geographic area will your project reach?*
How did you hear about the Smile Kit program?*
Which of the following grant and program criteria best applies to your program? Select only one answer.*

Type of facility or requesting organization:*




If other, please explain
What dental services are offered along with the distribution of Smile Kits?*



SMILE KIT REQUEST
Number of kits for ages 8+*
If you need more than 1000 smile kits for ages 8+ please enter the number here in increments of 50.
Number of kits for ages 4-7*
If you need more than 1000 smile kits for ages 4-7 please enter the number here in increments of 50.
Have you received kits in previous years?*

Is your organization tax exempt?*

If yes, please make sure to upload your U.S. Treasury (IRS) tax determination letter proving your organization's non-profit status. If you do not upload it now, you'll have two days to email a current copy to corpcomm@deltadentalks.com or fax it to 316.462.3372. 

If no, a tax determination letter is not required and no additional steps are necessary.

U.S. Treasury tax determination letter/Tax exempt letter