Apply for the OHE Pilot Program | Oral Health Education

Application Type

Choose individual participation or a group of two to five proposed participants.

IndividualOne proposed participant.

GroupTwo to five proposed participants.

Primary Applicant / Contact

The person submitting the application may be an organizational or administrative contact and does not have to participate.

Full Name *

Email Address *

Phone (optional)

Relationship to Organization *

I am also a proposed participant in this application.

Organization and Proposed Implementation Location

Identify the organization or community and where the proposed implementation is expected to take place.

Organization / Community Name *

Organization / Community Type *

Implementation City *

State / Province *

ZIP / Postal Code *

Country *International participation is subject to prior case-by-case evaluation and approval.

Proposed Participant(s)

Each proposed participant must provide an individual email address they personally control. Each person receives a separate verification and policy acceptance link.

Proposed Community Activity

Provide brief information to support review of the proposed pilot setting.

Briefly describe the community or population you intend to serve. *

Why are you interested in participating in the OHE Pilot Program? *

Application Acknowledgments

These acknowledgments are not acceptance of the Pilot Program Policy. Policy acceptance is completed individually through each proposed participant's email.

Before submitting

I understand that each proposed participant must have access to their own individual email address.

I understand that each proposed participant will receive an individual email requiring them to verify access to that email address, review the OHE Pilot Program Policy, and confirm participation within the required confirmation period.

I understand that only participants who complete the individual verification and acceptance process on time may be considered for participation.

I certify that the information submitted is accurate and that participant contact information is being provided for the purpose of this Pilot Program application.

What happens next: Each proposed participant receives an individual verification email immediately after submission. The confirmation link is time-limited. Participants who do not complete verification and policy acceptance before the deadline cannot be included in the Pilot Implementation associated with this application.

Submission does not guarantee acceptance into the Pilot Program.

✓

Thank You for Your Interest in the OHE Pilot Program

Your application has been submitted for review by Mobile Dental Services.

Application ID: Generated by production server

Each proposed participant must now use the individual email sent to them to verify their email address, review the Pilot Program Policy, and confirm participation within the required confirmation period.

Mobile Dental Services will evaluate the application and the participants who completed confirmation on time. A response is generally issued within approximately 48–72 hours.

Please monitor the email addresses provided, including spam or junk folders.

Submission does not guarantee acceptance into the Pilot Program.