1-Day Enrollment

1-Day EFDA & Radiology Enrollment

Dental Assisting Academy of the Palm Beaches 1-Day Enrollment Application for the EFDA or Dental Radiology Course. You only need ONE application if you are taking BOTH classes on the SAME day. Please be advised: Once you have confirmed your spot with the Academy, an ADDITIONAL $100 fee will be applied if you cancel or change class dates AFTER confirmation.
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
Date of Birth *

Month Day Year
Name of Emergency Contact *

First Name Last Name
Emergency Conctact Phone# *

Area Code Phone Number
What date did you want to start the course/courses? If you're not sure, please refer to our schedule page *

Month Day Year
What courses did you want to take? *Select all the apply *

EFDA Radiology
EFDA & Radiology are held on FRIDAYS: When did you want to take the Course(s)? *

November 12th (1 Seat Available) November 19th (4 Seats Available) December 3rd (4 Seats Available) December 10th (4 Seat Available)
How long have you been a Dental Assistant? *
* If you are a Dentist from another country please state which country you practiced in and what year you have obtained your license *
What is the name of the Dentist that you work for? *
Dental Office Phone Number *

Area Code Phone Number
What name would you like to have PRINTED on your Certifications? Please remember to add middle or other names wanted, and check spellings. *
Will you be needing Language Translation assistance? *

Yes No
*Language Translation assistance will only apply to those students whose primary language is not English for the written mulitple choice examinations for the courses* Google Translate will be provided as an option for assistance.
How did you hear about this class? *

Please answer the following skill questions: *

	Never Performed	Low-Proficiency	Medium-Proficiency	High-Proficiency	Mastered Skill
Dental Impression
Pouring Stone Model
Trimming Stone Model
Coronal Polishing
Tofflemire Matrix
Dental Sealants
Rubber Dental Dam
Cord Packing
Creating Temporary Crown
Trimming Temporary Crown
Cementing & Cleaning Temporary Crown
Manual Blood Pressure & Vital Signs
Dental Radiology

Virtual Signature binds the Student to Terms and Conditions of the Academy *

Clear
Please upload a copy of your Drivers License, Passport, or other issued Government ID *

Browse Files

Cancel of
Notes & Comments:
Class Enrollment *
prev next ( X )
Expanded Functions Dental Assisting Course $ 345.00

Radiology Course $ 285.00

Total $ 0.00
Should be Empty:

1-Day EFDA & Radiology Enrollment