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F
OR OFFICE USE ONLY


REC’D________

COMPLETE INFO______

INPUT________


Secret Smiles of Dayton, Inc.


P.O. Box 291903, Dayton, OH 45429-0903
www.secretsmilesdayton.org


Application Guidelines


  1. The applicant must have demonstrated a desire and initiative to improve his/her situation. Our hope is to provide assistance to families who are most likely to see Secret Smiles’ gift as an act of kindness that they can “pay forward” rather than a handout. Applicants CANNOT apply directly for assistance (see Instructions below).

  2. The referring agency/person must have a relationship with the applicant and be able to serve as a reliable reference and intermediary for the applicant. Referrals can come from social workers, teachers, pastors, or any representative of a social service agency or non-profit organization who has an ongoing relationship with the applicant.

  3. Only families with children in need will be accepted.

  4. A working phone number for the applicant must be provided.

  5. The applicant must have permanent housing and be in a stable living environment.

  6. The applicant’s home/apt. must be bed bug free for at least 2 months.

  7. In general, Secret Smiles provides twin beds and convertible cribs for children. If a child is extremely large, a full bed may be requested. Bedding is also provided for all beds.

Instructions

All applicants who need beds for their children must work with someone who will serve as a referral for them. They cannot apply to Secret Smiles directly. The referral contact person needs to fill in the information requested below (pages 1 & 2) and take the following steps as part of Secret Smiles of Dayton’s application process:

  1. Complete information regarding applicant and his or her family and children under “Applicant Information” on page 3 of this form.

  2. The Referral will need to assist the applicant in completing a letter to submit with this form.

  3. Sign and date the form where indicated on page 2. Send the completed form to info@secretsmilesdayton.org (PDF or completed soft copy of this form is preferred).

  4. By signing below, you agree to be the main point of contact in providing assistance to this applicant, including coordinating delivery of beds and other items.

  5. Please refer to the Secret Smiles Application Guidelines above before sending in your referral.

Required Referral Information

Referral Name:






Your Title/Organization:




Your Email Address:




Your Phone Number:




Name of Applicant:




How long have you known Applicant:




Describe type of assistance needed by the Applicant – how many beds, for whom, what size bed is needed (double, twin or crib):



Provide background regarding family and how this assistance will benefit them (e.g., what are their personal circumstances, how is the Applicant parent coping under the circumstances, what kind of effort is she/he making to get back on track, do the children have any special needs, etc.) If possible, please provide examples.










Has the Applicant’s home/apt. been free of bed bugs for at least 2 months?

(If not, please explain why and what plans are being made to remove the pests.)






Has the Applicant ever applied for assistance from Secret Smiles in the past?

(If so, please provide details.)






Confidentiality: All information provided will be held confidentially by Secret Smiles of Dayton.
THANK YOU FOR YOUR HELP!
Electronic Referral Signature: _____________________ Date:_______________

Applicant Information


Name:




Age:




Address:
(Include apt, number if applicable, city and ZIP)




Phone Number(s):




Children:

(Please list names and ages of children and indicate which children need beds)






Letter:

Please write Secret Smiles a letter and let us know about your personal situation, including why you need beds for your family and help from Secret Smiles. You can tell us about your hopes and dreams, your home, your children, your work situation and aspirations, your personal education plans and accomplishments and/or those of your children, any volunteer activities you are involved in, etc.


Note to Applicant: Secret Smiles of Dayton will hold this information confidentially. Thank you!

Sincerely, ___________________


Print Name: ________________


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