A North Carolina Non-Profit Foundation

3055 Old Buies Creek Road, Angier, North Carolina 27501

www.tomakeachildsmile.com

APPLICATION FOR ASSISTANCE

If you know of a child in need of assistance, please complete the following form in its entirety and send to the Board Members of To Make a Child Smile Foundation.  Upon receipt of the completed application, the Board Members will review the information in its entirety.  The Board Members will make a determination if the foundation will be able to offer any assistance based on our guidelines.  Once a decision has been made, you will be contacted by a Board Member.

Name_____________________________________________________________

Address___________________________________________________________

Telephone Number(s)________________________________________________

Age____________                  Date of Birth____________     Gender_____________

School Grade_________________   Sizes______________________________

Briefly explain why you are applying for assistance________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________
Application Submitted By:

Name____________________________________________________________

Telephone Number__________________   
Relationship to child_________________