A Texas Non Profit Organization

GRANT APPLICATION

NUMBER OF MEMBERS IN HOUSEHOLD
WORK HISTORY
DEMOGRAPHICS(For Statistical Purposes)
Do you get any of the following benefits?(Required)

DENTAL

Please identify the type of procedure(s) you are seeking (if unsure, please leave blank):
OTHER
DISCLOSURE

AFFORDABLE BRACES FOR EVERYONE OF TEXAS (ABE)

GRANT APPLICANT / RECIPIENT AGREEMENT

Effective January 1, 2019

As an applicant, or potential recipient of a grant from the ABE, I agree to the following terms:

1. I certify that any funds which may be disbursed to me by a ABE Sponsor will be used only for the purpose of a cosmetic dental treatment plan.

2. Should I not undertake the procedure within 3 months of receipt of the Grant allocation, I will forego my consideration.

3. I am responsible for informing the ABE of any change or changes in my name or address during the period of time comprised of applying for a Dentistry Grant, and receipt of any Grant proceeds that may be awarded.

4. I agree that ABE may provide my information to authorized dental practitioners, their respective staff, third-party agents, volunteers or subsidiaries, for the purpose of booking my assessment and consultation, and to communicate with me regarding the status of my grant application; and/or to perform functions such as customer service, etc.

5. I agree to allow the ABE to publicize the grant to me without prior notification to me. (We will not identify the nature of your treatment.)

6. I agree that the ABE may use my name, as well as other independently gathered information about me that is already in the public domain.

7. I am aware that this includes, but is not restricted to, publication in the ABE Newsletter, Corporate Sponsorship campaign advertisements, letters and brochures.

8. If I am awarded a Grant, I will write a thank-you letter to the ABE Organization that acknowledges the award.

9. I certify that I am at least 18 years of age.

10. By submitting this application, I am giving permission to ABE and/or its affiliates to contact me via email, via text, via a phone call or via regular mail at the email, the phone numbers and/or addresses provided in this application. I understand, that I will be responsible for any charges associated with any such contact by ABE and/or its affiliates.

11. I agree to sign up for a monthly newsletter from ABE/ABE Affiliates/Sponsors/Advertisers which will be sent to the email provided in this application for a Grant. I understand that I can unsubscribe to this newsletter at any time by following the unsubscribe instructions provided in the newsletter.

12. Any grants awarded are towards the actual dental treatment only. Applicants are responsible for arranging for transportation to and from their assigned provider and/or lodging arrangements close to their assigned provider at their own cost. A dental treatment may require several visits, so applicants should factor in any travel and/or lodging costs associated with their treatment and understand that these costs are the applicant’s responsibility. Currently this program is only available in the Dallas-Fort Worth Metroplex. Anyone can apply but they need to be aware and understand that the treating dentists will be in the Dallas-Fort Worth Metroplex area.

Submitting an application for a Affordable Braces for Everyone of Texas confirms you have read, understand and agree to the terms of these guidelines and agree to comply with them.