TDAS Course Admission Form

TDAS Admissions Form

Please fill out the form below to enroll for the class.
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail
example@example.com
Mobile Number
Phone Number
How did you hear about Tulsa Dental Assisting School?

Online SearchSocial Media Post/AdCurrent School/CounselorCareer FairWord of mouth/former studentOther
Why do you want to enter the dental field?
Do you have reliable transportation for your internship?

YesNo
Professional Reference 1

First NameLast Name
Reference 1 Phone Number
Please enter a valid phone number.
Payment Options
Please choose from the payment options below:

1. Payment in full by cash, check, money order, ACH will receive a 5% discount = $3562.50

2. Financed by Care Credit = $3950

3. Payment Plan = $3750. Initial down payment, plus 5 monthly payments. If you chose this payment option, we will need the down payment amount to be made before you can access your online materials. See payment plan options below:
Please select your payment option below:
If choosing the Payment Plan, please select which option below:
Signature

Clear
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

TDAS Admissions Form