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DENTAL ASSISTING PROGRAM ENROLLMENT

YOUR FUTURE BEGINS NOW!

I am a

New Student

Current Student / ASDA Alumni

Name of Dental Assisting School

I agree to:(Required)

Provide a Certificate of completion on a Dental Assistant Program

To an entrance interview with school President

Provide a valid ID

Choose Your Class(Required)

Your Information

Name(Required)

First Last

Email(Required)

Phone(Required)

SSN(Required)

Date of Birth(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Name of Parent, Guardian or Spouse(Required)

First Last

Phone of Parent, Guardian or Spouse(Required)

Education Information

Graduated High School?(Required)

Yes

No

Name of Your High School(Required)

GED

Attended College or Technical Institution?(Required)

Yes

No

Name of College or Technical Institution(Required)

Graduated College?(Required)

Yes

No

2 or 4 Year Degree?(Required)

Date of Graduation(Required)

College Address

Street Address City State / Province / Region ZIP / Postal Code Country

Emergency Contact

Name of Emergency Contact(Required)

First Last

Phone of Emergency Contact(Required)

Relationship(Required)

Address of Emergency Contact(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Payment

Payment Option(Required)

$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(Required)

$200 Registration Fee (Reserve your seat in the class)

$5,000 Total Tuition Fee (Tuition includes books and supplies)

Payment Option(Required)

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

Payment eLearn(Required)

$5,050 Total eLearnTuition Fee (Tuition includes ebooks and supplies)

Payment Ortho(Required)

$200 Registration

$200 Registration + $1,300 Tuition

Payment Ortho Alumni(Required)

$200 Registration

$200 Registration + $800 Tuition

Payment Pedo(Required)

$200 Registration

$200 Registration + $1,300 Tuition

Payment Pedo Alumni(Required)

$200 Registration

$200 Registration + $800 Tuition

Payment Custom(Required)

Total

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Month Year Expiration Date

Security Code Cardholder Name

Electronic Signature

I agree

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

By clicking “SUBMIT” you agree to the Arizona School of Dental Assisting's Terms and Conditions and Privacy Policy.

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Student Payment (Custom)

Comments

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