Henry Schein NDA SMILE Program – Student Application

APPLICATION INSTRUCTIONS

Option 1: Complete the online form below.

Option 2: Download and complete the Microsoft Word version of the application, then email the completed form to [email protected].

Student's Legal Name(Required)

First Last

Preferred Name

Date of Birth(Required)

Gender(Required)

Student's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Student's Email(Required)

Student's Phone(Required)

Race(Required)

T-Shirt Size(Required)

School(Required)

Grade(Required)

Program Choice(Required)

Personal Statement(Required)

Please provide a few sentences as to why you’d like to participate in this program.

Prior Experience

Please share any prior experience attending healthcare or STEM (science, technology, engineering & math) programs.

Relationship to Student(Required)

Guardian's Legal Name(Required)

First Last

Guardian's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Cell Phone(Required)

Occupation(Required)

Employer(Required)

Parent/Guardian Signature