Patients Treated
$145 million
In Free Oral Health Care

Apply for a Mission of Mercy Grant

First Name:*
Last Name:*
Name of MOM:*
Date of Application:*
Name of Sponsoring 501(c)(3) :*
Location of Event:*
Date of Event:*
Person Applying for Grant :*
Job Title:*
1. Projected number of patients to be treated:*
2. Projected number of dental professionals to volunteer:*
A. Dentists:*
B. Hygienists:*
C. Dental Assistants:*
3. Projected Number of Community Volunteers:*
4. Is this your first MOM event? If NO, Please complete A-F:* YES  NO
A. What was the budget for your last event?:
B. How many patients did you project serving at that event?:
C. How many patients did you actually serve?:
D. Amount of funds from any prior events to apply to this event:
E. Were your previous event(s) well organized and set to high professional standards?: YES  NO
F. Is there an endowment fund for your MOM events?: YES  NO
F-a. If YES, how much is that endowment?:
5. Specific budgeted items for this event where any Patterson Foundation funds would be applied:*
What percentage of funds have you secured for this event? Budget with line items for expenses and revenues must be submitted for grant consideration:*
7. Are you willing to comply with all covenants of the ADCF contract?:* YES  NO
8. Have you ever formally applied for funds from Patterson Foundation for previous events?:* YES  NO
8-a. If YES, When did you last apply?:
9. Have you ever received funds from Patterson Foundation for a previous event?:* YES  NO
9-a. If YES, how much did you receive?:
10. Is Patterson involved with your event?:* YES  NO
10-a. If YES, What is the name of your contact?:
10-b. What is the contact number for that person?:
11. I have reviewed the criteria for Patterson Foundation MOM grants and all the information in this application is accurate at this time.:* YES  NO
Please enter the text you see:

America's Dentists Care Foundation
Missions of Mercy
9110 E. 35th St. N
Wichita, KS 67226

Phone: 316-260-5056

Connect with us
on Facebook!

Home  | Get Involved  | See for Yourself  | The Foundation  | ADCF Supporters  | Contact  | Log-in  | Images  | Videos  | Testimonials  | About Us  | Meet the Board  | Meet the Team  | Make a Donation  | Volunteer  | Find an Event  | Our Supporters  | 2016 Year-to-Date Contributions

America's Dentists Care Foundation does not provide free dental care. If you are in need and there is not a MOM planned in your area, please contact your state dental association for any outreach clinics that may be in your area. Visit the Find an Event page to find a MOM near you!

America's Dentists Care Foundation (ADCF) | www.adcfmom.org | 316-260-5056
9110 E. 35th Street N, Wichita, KS 67226



Copyright © 2014-2016 America's Dentists Care Foundation (ADCF) and WEO MEDIA. All rights reserved.  Sitemap | Links | Login