Skip Navigation Skip to Footer Links
Smile Kit Application Teachers

Smile Kit Program Application for Teachers

Delta Dental of Kansas' Smile Kits include a toothbrush (youth or child size), travel sized toothpaste and floss. 

Date:*
RadDatePicker
RadDatePicker
Open the calendar popup.
SCHOOL INFORMATION
School name:*
School district #:*
Street address (Smile Kits will ship here):*
City:*
State:*
Your school must have a physical presence in the state of Kansas.
ZIP:*
Contact name:*
Grade level(s) taught:*
Email address (used for contact purposes):*
Phone number:*
ORAL HEALTH EDUCATION/OUTREACH COMPONENT INFORMATION
Project/Program name:*
Project/Program purpose:*
Describe the oral health education/outreach component of your project/program:*
Are you using Delta Dental of Kansas' Kids Wellness Program as your oral health education/outreach component?

If yes, please check which Kids Wellness Program challenges you are planning to use:




Does your project/program target uninsured or underserved students in Kansas? If yes, please explain:
Project/Program start date (within 2017/2018 school year):*
Number of students effected by project/program within 2017/2018 school year:*
How did you hear about the Smile Kit program?*
SMILE KIT REQUEST
The total number of Smile Kits requested must be in increments of 50. The minimum amount of kits you can select is 50 per toothbrush size. In order to meet the minimum order we suggest collaboration among teachers/grade levels. 
ADULT KITS (Indicate how many kits you're requesting for age 8+)*
CHILD KITS (Indicate how many kits you're requesting for ages 4-7)*
UserEmailAddress*
Have you received Smile Kits in previous years?*