Houston Pure Dental Academy - 2023 Application

Application

Houston Location
Pure Dental Assistant Academy
419 W. Little York Suite H
Houston, Texas 77076
(469) 912-0299 Info@puredallas.com
"Dental Assisting" Program Information and Qualifications

Students must have a High School Diploma, GED, or college transcript.

Students must pass a background check to be accepted to the Pure Dental Academy Dental Assisting Program.

Tuition: Program Cost $4,000- MINT Dentistry Scholarship of $1000 included reducing the total program cost to $3,000. Included: Student Workbook, Unlimited access to Evolve Textbook, One set of scrubs, Dental supplies for all Labs, BLS/CPR certification, Nitrous Oxide Monitoring voucher code for certification through TSBDE, and the TSBDE Registered Dental Assistant State Board Exam voucher code. Additional Costs associated with TSBDE will be a $39 application fee, a $36 fingerprinting fee with a state-appointed 3rd party agency, and a $6 National Public Database personal inquiry will be the student's responsibility.*

Course Information: Dental Assisting Course with a Unique hands-on approach, Taught in a clinical office setting. 136 total class hours are required to complete the program. A total of 6 Weeks of in-person, on-campus instruction is required. A 40-hour externship at a Dental office will be considered Week 7. Once students complete their 96 in-class hours, they will receive a voucher code to complete their State Exam provided by the Texas State Board of Dental Examiners. Tuition must be paid in full before the Student will be allowed to take the State Board Exam.

Each class day will consist of 4 hours, Monday through Thursday.

Upon completion of your application, a $100 non-refundable deposit is required to finalize your application. This deposit will be deducted from the total tuition cost. Once your application and background check have been processed, our PURE Dental Academy staff will contact you regarding the next steps, which include a minimum tuition deposit to secure a spot in the class.*

*Fee is estimated and based on current cost and subject to change

*The $100 non-refundable fee will not secure your seat in class.

Note that any payments made are deducted from your overall tuition total of $3,000
Form was revised on April 25, 2023

Personal Information
Date*

MonthDayYear
Date
Name*

First NameMiddle InitialLast Name
Address*

Street Address

Apt#

CityState

Zip Code
Phone Number*
Email*
example@example.com
Date of Birth*

MonthDayYear
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Social Security Number*
Gender*
United States Veteran or Military Member*

YesNo
Scrub Sizes
Race

Emergency Contact
Relationship*
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email
Are you currently employed?

YesNo
Name of Employer
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Employer Phone Number
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Tuition
Please select how you would like to proceed with your tuition payment options:*

The Student plans to pay in fullThe Student plans to select a payment plan once their initial tuition deposit is received
No interest will be charged for any of the above payment plans.

ALL Payment plans will be created on the first day of class.
Choose Method of Payment (payment not required to apply | Upon completion of your enrollment, a $100 non-refundable deposit is required to secure your spot in the class. This deposit will be deducted from the total tuition cost.):*

Money OrderCashDebit or Credit Card
"Any holder of this consumer credit contract is subject to all claims and defenses which the debtor could assert against the provider of post-secondary education obtained pursuant hereto or with the proceeds hereof. Recovery here under the debtor shall not exceed the amounts paid by the debtor here under"

A full refund will be made to any student who cancels the enrollment contract within 72 hours (until midnight of the third day, excluding Saturdays, Sundays, and legal holidays.) after the enrollment contract has been signed. A full refund will also be made to any student who cancels enrollment within the student's first three scheduled class days, except that the school may retain not more than $100 in any administrative fees charged, as well as items of extra expenses that are necessary for the portion of the program attended and stated separately on the enrollment agreement.

How did you hear about us?
Referral:

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Referral Name

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Signatures
Cancellation Policy*
Refund Policy*
Acknowledgments*
Approved and regulated by the Texas Workforce Commission, Career Schools and Colleges, Austin, Texas.
Student Name*

First NameLast Name
Student Signature*
Date*

MonthDayYear
Date
Parent or Guardian Signature
Date

MonthDayYear
Date
Once you select submit on this application, do not exit out of your screen. You will be redirected to complete your background authorization form. In order for us to process your application and background, both of these forms are required.