• DASA Digital Enrollment Packet

  • Dental Assisting School of Arizona, LLC
    2233 West Baseline Rd. #104
    Tempe, AZ 85283
    (602) 388-0028
    Fax: (602) 438-8695
    Email: dentalassistingschoolofaz@gmail.com
    Website: https://dentalassistingschoolofphoenix.com
    Equal Opportunity Employer/Program
  • Applicant Cover Sheet

  • Available class time: Saturday 8:00 AM–3:00 PM.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • If a Social Security number is required for the student record, DASA will collect it separately in person.
  • PROGRAM INFORMATION:

  • 2.) Program: Dental Assisting
    4.) Program Length: 128 hours
    (Specified in clock hours) – 13 weeks
  • 3.) Start Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • 5.) Completion Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • 5 a.) TUITION AND FEES:

  • All students enroll for a complete program and pay tuition for the complete program prior to entrance unless other arrangements have been made. Tuition includes books and supplies:
    5 b.) Course Tuition Registration Fee Books/Supplies Total
    Dental Assisting $5,150.00 $200.00 $150.00 $5,500.00
  • The registration/administration fee must accompany the Enrollment Agreement to secure a space in the program and shall be applied to the first installment or full payment upon enrollment.
  • Page 1 of 6
  • TUITION PAYMENTS:

  • To assist students who are financially not capable of paying the full tuition up front, the school will offer an interest free easy installment plan. These terms are available to all students who need assistance. The plan will consist of four (4) installments:

    1st installment upon enrollment - $ 1,375.00

    2nd installment on the 4th week of class - $ 1,375.00

    3rd installment on the 8th week of class - $ 1,375.00

    4th installment on the 12th week of class - $ 1,375.00

    Total Payment - $ 5,500.00
  • LATE PAYMENT:

  • Tuition must be paid either prior to entrance or prior to the month in which it is due. All payments must be paid by one week prior to the end of the program. Installment payments not received by the due date shall incur a five percent (5%) penalty of the amount due in addition to the $50.00 late fee.
  • 6.) CANCELLATION AND REFUND POLICY:

  • (To comply with R4-39-308 and R4-39-404)

    An applicant denied by the school is entitled to a refund of all monies paid.

    Three-Day Cancellation: An applicant who provides written notice of cancellation within three days (excluding Saturday, Sunday and federal or state holidays) of signing an enrollment agreement is entitled to a refund of all monies paid. No later than 30 days of receiving the notice of cancellation, the school shall provide the 100% refund.

    Other Cancellations: (Required by R4-39-404A) An applicant requesting cancellation more than three days after signing an enrollment agreement and making an initial payment, but prior to entering the school, is entitled to a refund of all monies paid less $200.00 of registration fee and $150.00 of book/supplies fee (if Kindle Fire, books and supplies are not returned to the school).

    Refund after the commencement of classes:

    1. Procedure for withdrawal/withdrawal date:

    A. A student choosing to withdraw from the school after the commencement of classes is to provide written notice to the Director of the school. The notice is to indicate the expected last date of attendance and be signed and dated by the student.
  • Page 2 of 6
  • B. For a student who is on authorized Leave of Absence, the withdraw date is the date the student was scheduled to return from the Leave and failed to do so.

    C. A student will be determined to be withdrawn from the institution if the student has not attended any class for 6 consecutive class hours.

    D. All refunds will be issued within 30 days of the determination of the withdrawal date less $200.00 of registration fee and $150.00 of book/supplies fee (if Kindle Fire, books and supplies are not returned to the school).

  • 2. Tuition charges/refunds:

  • A. Before the beginning of classes, the student is entitled to a refund of 100% of the tuition less $200.00 of registration fee and $150.00 of book/supplies fee (if Kindle Fire, books and supplies are not returned to the school).

    B. After the commencement of classes, the tuition refund amount, less $200.00 of registration fee and $150.00 of book/supplies fee (if Kindle Fire, books and supplies are not returned to the school), shall be determined as follows:

  • B. After the commencement of classes, the tuition refund amount, less $200.00 of registration fee and $150.00 of book/supplies fee (if Kindle Fire, books and supplies are not returned to the school), shall be determined as follows:
    % of the clock hours attended: Tuition Refund amount:
    10% or less 90%
    More than 10% and less than or equal to 20% 80%
    More than 20% and less than or equal to 30% 70%
    More than 30% and less than or equal to 40% 60%
    More than 40% and less than or equal to 50% 50%
    More than 50% No Refund is required
  • The percentage of the clock hours attended is determined by dividing the total number of clock hours elapsed from the student's start date to the student's last day of attendance, by the total number of clock hours in the program.

    Timely Refund Payments: Refunds shall be paid within 30 days of the date of student notification, or date of school determination (withdrawn due to absences or other criteria as specified in the school catalog), or in the case of a student not returning from an authorized Leave of Absence (LOA), within 30 days of the date the student was scheduled to return from the LOA and did not return.

    Books and Supplies: There is no refund for any equipment, books and supplies unless returned by the student to the school. Fees for books and supplies are subject to cost change.

    Refund of Special and Unanticipated Cases: In case of prolonged illness or accident, death in the family, or other circumstances that make it impractical for the student to complete the program, the school may make a settlement which is reasonable and fair.

  • Cancellation of Program or School Closure

  • If a course or program is discontinued or canceled or the school closes prior to completion of contract services, a refund of all tuition fees shall be made by the school to the students.
  • 7.) Holder in Due Course Statement:

  • Any holder of this consumer credit contract is subject to all claims and defenses which the debtor could assert against the seller of goods or services obtained pursuant hereto or with the proceeds, hereof Recovery hereunder by the debtor shall not exceed amounts paid by the debtor (FTC Rule effective 5-14-76).
  • THE STUDENT UNDERSTANDS:

    1. The School does not accept credit for previous education, training, work experience (experiential learning), or College Level Examination Program (CLEP), if applicable.

    2. The School does not guarantee job placement to students upon program/course enrollment/completion or upon graduation.

    3. The School reserves the right to reschedule the program start date when the number of students scheduled is too small.

    4. The School will not be responsible for any statement of policy or procedure that does not appear in the School catalog.

    5. The School reserves the right to discontinue any students' training for unsatisfactory progress, nonpayment of tuition or failure to abide by School rules.

    6. Information concerning other Schools that may accept the School's credits toward their programs can be obtained by contacting the office of the President. It should not be assumed that any programs described in the School catalog could be transferred to another institution. The School does not guarantee the transferability of credits to a college, university or institution. Any decision on the comparability, appropriateness and applicability of credits and whether they should be accepted is the decision of the receiving institution.

    7. This document does not constitute a binding agreement until accepted in writing by all parties
  • Page 4 of 6
  • HOLD HARMLESS AGREEMENT

  • The Dental Assisting School of Arizona and student acknowledge that there is some risk of accident or injury associated with use of equipment and other aspects of the course of study, including but not limited to direct care and contact of other students, clients, patients, or residents at the clinical or training facility site. Student does hereby waive, release and discharge The Dental Assisting School of Arizona of any and all liability and all claims for damages for death, personal injury or property damage which may have or which hereafter accrue to me as a result of participation in the program whether or not caused by negligence or fault of The Dental Assisting School of Arizona.

    This release is intended to discharge the school and its officers, employees, representatives, students, volunteers and agents from and against any and all liability arising out of or connected in any way with my participation in the training, internship/externship, hands-on activities, practice or other activities.

    Knowing risks exists, nevertheless, I hereby agree to assume those risks and to release and to hold harmless all persons or agencies mentioned above that might otherwise be liable to me or my heirs or assigns for damages. I further understand and agree that this waiver, release and assumption of risk are to be binding on my heirs and assigns.

    In addition, I give permission to receive, if necessary, emergency medical services by authorized personnel and that any cost incurred as a result of such medical treatment will be my responsibility.
  • STUDENT ACKNOWLEDGEMENTS:

  • CONTRACT ACCEPTANCE:

  • I, the undersigned, have read and understand this agreement and acknowledge receipt of a copy. It is further understood and agreed that this agreement supersedes all prior or contemporaneous verbal or written agreements and may not be modified without the written agreement of the student and the School Official. I also understand that if I default upon this agreement, I will be responsible for payment of any collection fees or attorney fees incurred by The Dental Assisting School of Arizona.

    My signature below signifies that I have read and understand all aspects of this agreement and do recognize my legal responsibilities regarding this contract.
  • Signed this day of 20
     - -
  • Date (Student)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Will the student be under 18 on the program start date?*
  • For DASA Administration Only

  • Representative certification for post-submission processing.
  • School Representative Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date (Parent)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date (School)
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Should be Empty: