Dental Assisting Application

Name *

First

Last

Address *

Address Line 1

City

State

Zip Code

Date of Birth *

Email *

Home / Cell *

Parent, Guardian, or Spouse Name

Parent, Guardian, or Spouse Home / Cell

High School/College

Year of Grad.

Please Select *

High School Graduate
GED
College

How I heard about this program *

In case of emergency contact:

Name *

Phone *

Relationship *

State, Zip *

Please select which class you would like to attend *

Session I
Session II
Session III
Session IV

I understand that there is a $40.00 nonrefundable application fee to be included as well as documentation of official high school transcript, official GED transcript, or official college transcript, we only need 1 official transcript. Without these two requirements my application will not be complete and sent back. Late fee is $150.00 *

I acknowledge this

In case of emergency contact:

Happy Holidays!