If you would like to register for the Middle School Braces Scholarship from Dr. Christopher West and Family Orthodontics, please fill out this entire form and press submit. You will receive a confirmation email that your registration has been received.

Student's Name
Mother's Name
Father's Name
Guardian
Street
Town
Phone
Email
My Child Attends:	Choose one Jupiter Middle Independence Middle (IMS)
Grade:	Choose one 6 7 8
How many children in the household under the age of 14?:	0  1  2  3  4+
Verification Code (case sensitive):

Every year the scholarship registration opens the first day of the school year, closes January 31st, the scholarship winners are announced around mid June. For a registrant to be considered, they must make an appointment with our office for a FREE consultation. Please contact the office at (561) 744-5456. We look forward to meeting you.