Section 1 of 1 in this document
Wisdom For Wisdom
I am a student between the ages of 17-21.
Yes
No
Student First Name
*
Student Last Name
*
Parent First Name
*
Parent Last Name
*
Email
*
Phone Number
*
Student's Birth Date
*
Student's Preferred Pronouns
*
City
*
State
Select applicant's current educational status
*
Choose One
High School Student
High School Graduate, Planning to Attend College
College Student
Current School Name
Current School Name
Current School Name
Current School City
Current School City
Current School City
Current School State
Current School State
Current School State
What College/University do you play to attend? (optional)
If graduating, what college/university do you plan to attend? (optional)
How did you hear about the Wisdom For Wisdom program?
*
Choose One
Facebook
Instagram
Email
Teacher/School
Community Organization
Flyer
News (TV, Newspaper, Online)
Other (if other, please specify
Other
Who is your general dentist?
When did you have your last cleaning appointment?
*
Choose One
Less than 6 months ago
6–12 months ago
12﹢ months ago
Have you been advised by a medical professional to have your wisdom teeth removed?
*
Choose One
Yes
No
Our Wisdom For Wisdom program is designed to offset college expenses by providing a complimentary wisdom teeth removal procedure. As a student or parent of a student, what would the Wisdom For Wisdom program mean to you if you are selected?
*
disregard this