How did you find this website?

Do your children have dental insurance or state Medicaid?

What is your zip code?

Number of people in your immediate family:

Do any of your children have
a dental emergency?

First Name:

Middle Initial:

Last Name:

Street Address:

City:

State:

Zip Code:

Home Phone:

Mobile Phone:

Email Address:

Your Ethnicity

Your Primary Language

Your Citizenship

NOTE: Your citizenship status does not affect your children's eligibility in this program.

TOTAL MONTHLY WAGES (after taxes)

$ *

NOTE: Include income from all immediate family members in
your household.

OTHER MONTHLY INCOME

$ *

Thanks. Now please make sure the following information about your household monthly income is correct.

TOTAL MONTHLY WAGES

$0/month    Change

OTHER MONTHLY INCOME

$0/month    Change

Based on what you have told us today, your children are:
   [likely to be eligible/NOT likely to be eligible] for the KC KIDS program.   WHY?

If your kids are likely eligible for the KC KIDS program, your next step is to complete an enrollment application. To learn how, proceed to STEP 2.

Now it's time to fill out an enrollment application for the KC KIDS program.

To send your application:

You can mail or fax your enrollment application. For details, proceed to STEP 3.

(You can also find our address and fax number on our Contact page).

When you have completed your enrollment application, please mail or fax it to us. Be sure to include proof of income for the past 30 days.

Examples of proof of income: Copies of payroll stubs or unemployment checks, written statements from employers, etc.