Keller Memorial Fund Application

Keller Memorial Fund

Application for support for Orthodontic Care

Through the Keller Memorial Fund

To apply by mail, download the application form by clicking the link below.

SELECTION CRITERIA

I. Applicants must currently reside in Greater Kirkland (Bothell, Kirkland, Kenmore, Redmond, or Woodinville).

II. The applicant must undergo an examination by a licensed orthodontist to determine that
required treatment is necessary and goes beyond simple cosmetics.

III. The applicant must also meet acceptable orthodontic standards that are verified by an
established practicing orthodontist.

IV. Parents or guardian must provide an explanation for why financial assistance is needed.

V. Parents or guardians must be fully committed to meeting all orthodontic appointments and care at the approved practicing orthodontist.

VI. As treatments begin and proceed, the Kirkland Kiwanis Foundation (KKF) will make pre-arranged periodic payments directly to the orthodontist practice.

VII. To maintain financial support to the conclusion of treatment, parents or guardians must stay current on the portion of the orthodontic fees agreed to in advance of entering this program.

VIII. Parents or guardians must sign the attached release form allowing the applicant’s image to be used in various literature and fund-raising activities associated with the Keller Memorial Fund.

LETTER OF AGREEMENT

Please download and sign a copy of the “Keller Memorial Fund Letter of Agreement to Participate” at the bottom of the form, below.

DOWNLOAD

"*" indicates required fields

Mission Statement

Working through either a licensed orthodontist or the University of Washington Department of Orthodontics, the Keller Memorial Fund will endeavor to help ensure that that children who otherwise might not be able to afford needed orthodontic treatment will have access to quality orthodontic care.

Background

Dr. Jack Keller was a respected orthodontist in the Kirkland area who died in a tragic hunting accident. Since Dr. Keller was a long-time member of Kiwanis, his family, friends, and associates worked with the Kirkland Kiwanis Foundation to form the Jack Keller Memorial Fund, which was established in 1986. Money contributed to the Kirkland Kiwanis Foundation in Dr. Keller’s name is used exclusively to help those in need gain access to quality orthodontic care, which otherwise might not be affordable.

Patient Details

Patient's Name*

First Last

Patient's Age*

Patient's School*

Parent/Guardian Details

Parent/Guardian Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Secondary Phone*

Email*

Parent/Guardian Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Primary Phone

Secondary Phone

Statement

Attach a copy of the assessment for need for orthodontic care. Submit this application and all supporting documentation to the orthodontist or the Kirkland Kiwanis Foundation.

Your Qualifications*

Please provide a statement of family income and any special financial needs because of family circumstances. Indicate whether the candidate is covered by dental insurance or receives other funding assistance that provides dental and/or orthodontic care.

Financial Statement*

Please upload your confidential statement of family income and any special financial needs as a result of family circumstances.

Max. file size: 100 MB.

Orthodontic Assessment*

Please attach a copy of the assessment for need for orthodontic care.

Max. file size: 100 MB.

Signed Release*

Please attach your signed copy of the “KELLER MEMORIAL FUND LETTER OF AGREEMENT TO PARTICIPATE”

Max. file size: 100 MB.

Additional Information

Please upload any additional information here.

Max. file size: 100 MB.

Parent/Guardian Signature

BY SIGNING THIS FORM: I hereby confirm that based on my understanding of the requirements of The Keller Memorial Fund that I have been provided, the candidate named below is eligible for assistance with needed orthodontic care through the Keller Memorial Fund. I understand that orthodontic care will be provided by an approved practicing orthodontist. I also understand that the Kirkland Kiwanis Foundation does not ensure the quality or outcome resulting from work done by the orthodontist. I also understand the outcome is dependent on good oral care and cleaning by the patient and family under the orthodontist’s supervision.

Parent/Guardian Signature*

Parent/Guardian Printed Name

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Date*

Name

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