Application Checklist.pdf

9/1/21
2405 Grand Blvd, Suite 300 | Kansas City, MO 64108 | Phone 816-421-4949

APPLICATION CHECKLIST
(Include this completed checklist with your application)

All of the items below must be FULLY completed and submitted to SCL for EACH child that is applying to the program.
□ Check the website to determine the availability of providers and average minimum wait time for your area.
□ General Application (pg 3-5)
□ Child “About Me” Page (REQUIRED): (page 6)
□ Notice of Privacy Practices (pg. 7 – MUST be signed by parent/guardian; child must sign if 18 or older)
□ Program Rules and Guidelines (pgs. 8 - All items MUST be initialed by parent/guardian; child must initial if 18 or older)
□ Parent/Legal Guardian Consent & Hold Harmless (pg. 9–MUST be signed by BOTH parent/guardian & child)
□ EIGHT (8) photos of the child are required
□ Federal Tax Form 1040 OR a Supplemental Security Income Awards Letter (US) / or a T4 and Tax Assessment or
Canada Child Benefit Form (Canada).
□ $30.00 (USD) non-refundable application fee

Documentation required for non-parental guardians:
□ Non-parental guardians must submit a copy of their authorization to make medical decisions (e.g. court order).
□ For children in state custody, copies of the child’s state medical card and medical consent must be submitted.

Mail COMPLETE application to:
Smiles Change Lives, 2405 Grand Blvd, Suite 300, Kansas City, MO 64108