Entry Form - Hillsborough County Sheriff's Office

“PERFECT SMILE” APPLICATION Dr. Stubbs Orthodontics has partnered with the Hillsborough County Sheriff’s Office to offer a back to school smile to a Hillsborough County child in need. Please see instructions and rules below for further information.

Instructions/Rules -- All sections need to be completed in full. -- Application must be typed or hand written legibly in ink. -- ONLY one contest winner. -- Child MUST have permanent teeth to participate. -- Child must be under 18 years old. -- Child must be a Hillsborough County resident. -- Parent(s) will need to display a financial need. -- A home visit will be required. -- Parent(s) must provide transportation for the services. -- All HCSO families are excluded from the contest. -- Application deadline July 20th, 2018. -- Return the application, a photograph of your child’s teeth, and a color copy of your child’s drawing to the Community Outreach Division electronically. -- Email: [email protected] with subject line “Perfect Smile.”

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PARENT INFORMATION (Write above the line) Last Name

First Name

Middle

Address City

County

Home Phone

State

Cell Phone

Date of Birth

Zip Code Business Phone

Social Security #

Height

CHILD INFORMATION (Write above the line) Last Name

First Name

Middle

Address City Home Phone Date of Birth

County

State Cell Phone

Current School

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Zip Code Business Phone

APPLICATION CERTIFICATION I certify that all information on this form is true and complete to the best of my knowledge. I provide consent for the release of information to verify the information contained in the application. I grant the Hillsborough County Sheriff’s Office the right to use any form or statements made by me, or both, for any lawful purpose. I give the Hillsborough County Sheriff’s Office permission to showcase before and after smiles on all social media platforms.

Parent or Legal Guardian Signature: ____________________Date: ________________

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