Application

ROYAL DENTAL ASSISTANT ACADEMY

APPLICATION
Name*

First NameLast Name
Middle*
DOB*

MonthDayYear
Date
Age*
Phone #*
Address*
City*
State*
Zip Code*
Email*
example@example.com
EMPLOYMENT AND EDUCATIONAL BACKGROUND
High School*
Graduation Year*

MonthDayYear
Date
College/University
Graduation Year

MonthDayYear
Date
Current/Most Recent Employer*
I am applying to enroll in:*

Dental Assistant I
Choose course term you wish to attend:*

SpringSummerFall
Choose schedule you would like to attend:

Saturday Morning Class 8-1pmHybrid Monday ClassTuesday & Thursday Night Class 6pm-9:30pmSpanish Class Saturday 11am-3pm
Emergency Contact Name*
Emergency Contact Phone #*
Relationship*
By signing below I attest that all the information provided is true and accurate to my knowledge. I understand there is a $50.00 Non-refundable Application Fee to be included with my application. Additionally, I understand that in order to reserve a seat there is a deposit required prior to my official acceptance into the program.
Signature

Clear
Date

MonthDayYear
Date

My Products

Application FeeApplication Fee

$50.00 Quantity

Total

$0.00

Credit Card

Afterpay

ROYAL DENTAL ASSISTANT ACADEMY