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* 1. School name:

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* 2. School district:

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* 4. School principal's name and contact information:

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* 5. Grant application submitted by:

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* 6. How many students are in your school?

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* 7. How many teachers and support staff are in your school?

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* 8. What percentage of your students are on the free or reduced-lunch program?

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* 9. Do you currently have any water bottle filling stations installed at your school?

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* 10. If yes, how many?

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* 11. Are students allowed to carry water bottles with them during the school day?

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* 12. Approximately how old is the water fountain you would like to replace?

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* 13. Where is the water fountain to be replaced located in your school?

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* 14. Please include photos of the current drinking water fountain that would be replaced by a new water fountain/bottle-filling station. Your photos should show the front and sides of the existing fountain as well as the surrounding environment (near a doorway, ledge, electrical outlet, etc). These photos are required to assist in determining the best equipment from the supplier and in preparation for the installation.

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* 15. Do the students in your school receive oral health education?

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* 16. If yes, please provide any details you can about the current oral health education they receive.

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* 17. Would you be interested in receiving materials to support oral health curriculum for your school?

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* 18. Does your school participate in a school-based oral health screening, fluoride or sealant program, or provide on-site oral health care to students?

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* 19. If yes, please provide any details you can about the current oral health services provided.

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* 20. Installation will be scheduled during summer break for your school. What are the dates students will be out of school for summer?

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* 21. Who is the best point of contact for scheduling the installation? 

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* 22. Who is the best point of contact for the installer when on-site?

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* 23. Please provide a link to the application video here. If posting on social media, please include #WatersCoolTN and be sure that the video is available for public viewing.

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