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DENTAL ASSISTING PROGRAM ENROLLMENT
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Jan Class 10am-1pm Tues/Thurs
Feb Class 6pm-9pm Mon/Wed
Mar Class 2pm-5pm Tues/Thurs
April Class 10am-1pm Tues/Thurs
May Class 6pm-9pm Mon/Wed
Jun Class 2pm-5pm Tues/Thurs
Jul Class 10am-1pm Tues/Thurs
Aug Class 6pm-9pm Mon/Wed
Aug Class 2pm-5pm Tues/Thurs
Oct Class 10am-1pm Tues/Thurs
Your Information
Name
*
First
Last
Name
*
First
Last
SSN
*
Date of Birth
*
Address
*
Street Address
City
Alabama
Alaska
Arizona
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Delaware
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Armed Forces Americas
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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?
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Yes
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Name of Your High School
*
Year of Graduation
*
GED
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2 or 4 Year Degree?
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Date of Graduation
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Arizona
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California
Colorado
Connecticut
Delaware
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Florida
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Idaho
Illinois
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Iowa
Kansas
Kentucky
Louisiana
Maine
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Massachusetts
Michigan
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Mississippi
Missouri
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Nebraska
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New Jersey
New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
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Name of Emergency Contact
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Phone
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Relationship
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Address
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Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
*
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Month
01
02
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04
05
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07
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Year
2021
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2025
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2027
2028
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2030
2031
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2033
2034
2035
2036
2037
2038
2039
2040
Expiration Date
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