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DENTAL ASSISTING PROGRAM ENROLLMENT

YOUR FUTURE BEGINS NOW!

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YesDentalAsissting

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YesOrtho

Choose Your Class

Your Information

This Ortho class is available for ASDA students only!

This Pedo class is available for ASDA students only!

Name(Required)

First Last

Email(Required)

Phone

SSN

Date of Birth

Address

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

Name of Parent, Guardian or Spouse

First Last

Phone of Parent, Guardian or Spouse

Education Information

Graduated High School?

Yes

No

Name of Your High School

GED

Attended College or Technical Institution?

Yes

No

Name of College or Technical Institution

Graduated College?

Yes

No

2 or 4 Year Degree?

Date of Graduation

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

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)

$6,050 Total Tuition Fee (Tuition includes books and supplies)

Payment Option(Required)

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

$5,800 Total Tuition Fee (Tuition includes books and supplies)

Payment Option(Required)

$5,800 Total Tuition Fee (Tuition includes books and supplies)

Payment eLearn(Required)

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

Regular price $6,050

Payment Ortho(Required)

$200 Registration

$200 Registration + $1,300 Tuition

Payment Pedo(Required)

$200 Registration

$200 Registration + $1,300 Tuition

Payment Custom(Required)

Total

Credit Card(Required)

American Express

Discover

MasterCard

Visa

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

Card Number

Expiration Date Month Year

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)

Email

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