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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*

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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 (Will be included in your Total Tuition Fee)
$50 Application + $200 Registration Fee (Reserve your seat in the class)
$5,000 Total Tuition Fee (Tuition includes books and supplies)

Payment Option*

$200 Registration Fee (Reserve your seat in the class)
$4,950 Total Tuition Fee (Tuition includes books and supplies)

Payment Option*

$4,750 Total Tuition Fee (Tuition includes books and supplies)

Grand Opening Special

Payment Amount*

Payment*

$3,500 Total eLearnTuition Fee (Tuition includes ebooks and supplies)

Orthodontic class

$250 Registration Fee (reserve your seat in the class)
$1,000 Total Ortho Tuition Fee

Orthodontic class

$250 Registration Fee (reserve your seat in the class)
$1,800 Total Ortho Tuition Fee

Total

$ 0.00

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DENTAL ASSISTING PROGRAM ENROLLMENT

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