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Grant Application

Thank you for reaching out! We know the cleft and cranofacial journey is long and we are here to help. Because of generous donors, Smile Oregon can provide grant support to children who qualify. Please read the following criteria before proceeding:

Grant Application - Criteria:
In evaluating applications, Smile Oregon will consider applications based on the following criteria:

  1. The individual receiving care must be 21 years old or younger.
  2. Smile Oregon gives priority to patients living in Oregon.
  3. The patient must be able to demonstrate a clinical and financial need.
  4. In order to be a sustainable organization every patient applicant will be asked to contribute resources based on their financial situation.

If you meet these criteria, we invite you to apply for a grant. Before starting the form, be sure to send the following two forms to your provider and have them returned to you before starting this application. (add link to Patient's Health Care Provider & Craniofacial Provider Forms) You will need the following documents to complete this application:

  • Current IRS form 1040EZ, 1040A, or 1040 (Please, include all responsible parties.)
  • Patient Photo 

We encourage you to collect these items prior to starting this application. You cannot submit your application until all parts of the form are complete. Once your application is submitted, you will receive a confirmation email. Typically, grants are approved within 30 days. For questions, please email us at info@smileoregon.org.

Thank You!

Patient Information
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First Name
Last Name
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(mm/dd/yyyy)
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First Name
Last Name
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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This section is for the patient to complete, NOT THE PROVIDER
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Please give all relevant details (i.e. cost(s), timelines, dates, etc.)
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Please explain

Please explain
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i.e. the school provides speech therapy

Please explain
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Please select one
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Financial Statement
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https://smileoregon.org/wp-content/uploads/2010/06/Health-Care-Provider-Form-.pdf
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https://smileoregon.org/wp-content/uploads/2010/06/Craniofacial-Team-Form1.pdf
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http://www.smileoregon.org/wp-content/uploads/2010/06/HIPAA-FORM.pdf