CONTACT US HAVE QUESTIONS ? GET IN TOUCH WITH US Address United States Email Susan@confidentkid.org Confident Kid Dental Charity Application for Funding To be accepted into the Confident Kid Dental Charity program the kid must: Be between the ages of 18 months and 18 years (19 years and older are not eligible) Live in Franklin County, Missouri Have a Missouri Medicaid Identification Number If a kid is accepted by the charity, the kid will be referred to a partnering dental practice in Franklin County. Dental expenses for maintenance and restorative care will be paid by Confident Kid Dental Charity. Unfortunately, orthodontic care is NOT included in services covered by Confident Kid Dental Charity.KID NAME First KID DATE OF BIRTH KID STREET ADDRESS Street Address Address Line 2 City ZIP Code COUNTY MISSOURI MEDICAID ID NUMBER SCHOOL PARENT/GUARDIAN NAME First PARENT/GUARDIAN STREET ADDRESS Same as previous Street Address Address Line 2 City ZIP Code PARENT/GUARDIAN PHONEPARENT/GUARDIAN E-MAIL I acknowledge that if scheduled appointments are missed, (if my kid has more than one “no show”) they may no longer be eligible for the Confident Kid Dental Charity program.(Required) I agree The following information is not required, however, the information will be beneficial in seeking additional grant funding for Confident Kid Dental Charity.RACE WHITE BLACK or AFRICAN AMERICAN HISPANIC or LATINO NATIVE AMERICAN or ALASKAN NATIVE ASIAN NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER MORE THAN 1 RACE HOW DID YOU HEAR ABOUT CONFIDENT KID DENTAL CHARITY?Submit application, including uploading a photo of your kid's Medicaid card.Upload photo of kid's Medicaid ID cardMax. file size: 512 MB.EmailThis field is for validation purposes and should be left unchanged.
