Enroll Now - azdentalassistants.com

I am a

New Student
Current Student / ASDA Alumni

Choose Your Class*

Name*

First Last

Your Information

Name*

First Last

SSN*

Date of Birth*

Address*

Street Address City State ZIP Code

Phone*

Email*

Name of Parent, Guardian or Spouse*

First Last

Phone of Parent, Guardian or Spouse*

Name of Dental Assisting School

Education Information

Graduated High School?*

Name of Your High School*

Year of Graduation*

GED

Attended College or Technical Institution?*

Name of College*

Graduated College?*

2 or 4 Year Degree?*

Date of Graduation*

College Address*

Street Address City State ZIP Code

Emergency Contact

Name of Emergency Contact*

First Last

Phone*

Relationship*

Address*

Street Address City State ZIP Code

Payment

registration

registration

tuition

tuition

custom

custom

elearn

elearn

check

check

ortho

ortho

Payment Option*

$50 Application Fee
$50 Application + $200 Registration Fee (Reserve your seat in the class)
$5,050 Total Tuition Fee (Tuition includes books and supplies)

Payment Option*

$200 Registration Fee (Reserve your seat in the class)
$5,000 Total Tuition Fee (Tuition includes books and supplies)

Payment Option*

$4,800 Total Tuition Fee (Tuition includes books and supplies)

Grand Opening Special

Payment Amount*

Payment*

$4,000 Total eLearnTuition Fee (Tuition includes ebooks and supplies)

Orthodontic class

$175 Registration Fee (reserve your seat in the class, part of total tuition)
$975 Total Ortho Tuition Fee

Orthodontic class

$175 Registration Fee (reserve your seat in the class, )
$975 Total Ortho Tuition Fee

Total

$ 0.00

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

By clicking “SUBMIT APPLICATION” and signing the Enrollment Agreement below, you agree to the Arizona School of Dental Assisting's Terms and Conditions and Privacy Policy.

*

I understand that checking this box and typing my name below constitutes a legal signature confirming that I acknowledge and agree to the above and electronically signing my application.

Electronic Signature*

Please type your full First and Last Name

Student Payment (Custom)

Name

This field is for validation purposes and should be left unchanged.

DENTAL ASSISTING PROGRAM ENROLLMENT

YOUR FUTURE BEGINS NOW!

Your Information

Education Information

Emergency Contact

Payment