Morrison Education Center

Applicant Information
Date

MonthDayYear
Contact Info
First Name*
Last Name*
Gender*

MaleFemale
Phone Number*
Email*
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Check here if physical address is the same as the mailing address.
Date of Birth*

MonthDayYear
Date
Please alert us of any allergies or health conditions that we may need to be aware of.*
Emergency Contact
Name*
Relationship*
Phone Number*
Address*
Work - Education - Certifications
Occupation*
Present occupation or past if not currently employed.
Employer
If applicable
Highest Level of Education*

High School (not completed)High School GradGEDCollege (not completed)College Grad
If high school grad give the name of your school and graduation year.
If currently enrolled in high school, give your anticipated date of graduation.
Are you CPR certified?*

YesNo
Are you X-Ray certified?*

YesNo
Uniform Information
Students will be supplied with and wear a MEC t-shirt and lab jacket to class and internship. Please select your preferred size below. Lab jackets are fitted, so please keep that in mind when requesting a size. Students must also wear black scrub pants to class and internship. This is the only required items students will need to purchase seperatly. Any brand scrub pants are acceptable.
Scrubs Jacket Size - Top*

X-SmallSmallMediumLargeX-LargeXX-LargeXXX-Large
T-Shirt Size*

X-SmallSmallMediumLargeX-LargeXX-Large
Internship Schedule Request
Students will complete 88 hours of hands-on internship during the course. These will be broken up weekly, completing 8 hours per week. Students have the option to fulfill this requirement during one full day of internship per week, or two half (4 hour) days. We understand and can accommodate busy schedules, but it is highly recommended that students complete one 8-hour day per week.

Internship schedules are determined on a first come, first serve basis. Only 1-2 students are able to intern at a time in order to allow for one-on-one instruction. Once the schedule has been posted; internship assignments are final.
Requested Internship Hours*

One 8 hour day each weekTwo 4 hour days each week
Internship Day(s) - First Choice*

MondayTuesdayWednesdayThursdayFriday
Internship Day(s) - Second Choice*

MondayTuesdayWednesdayThursdayFriday
Other Information
Why have you decided to become a Dental Assistant?*
Write one paragraph please.
How did you learn about Morrison Education Center?*

FacebookFlyerMorrison Dental Group newsletterWorkforce DevelopmentA current or former MEC studentInstagramGoogleMorrison Dental Group WebsiteSCHEVA MEC instructorLawn SignIn office at Morrison Dental GroupMorrison Dental Group FacebookA friend or family memberEvent at my high schoolMy guidance counselor
Did a specific person refer you to our school, and if so, what is their name?
Ethnicity*

HispanicBlack/African AmericanAmerican Indian/Alaskan NativeNative Hawaiian/Pacific IslanderAsianWhite/CaucasianPrefer not to answer2 or more races
Have you been convicted of a felony?*

YesNo
If yes, please explain
Questions?
If you have questions about payments, tuition, or our dental assistant program add them here or contact us at the office at (757) 258-7778.
Acknowledgement - Read and Check All Boxes*
Which class do you want to apply for? Please state the season (Spring, Summer, or Fall) and year.*
To view upcoming class dates, please see our Class Schedule.
Registration

$100
Coupon Code
How would you like to pay?*
Please verify that you are human*
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Applicant Information

Contact Info

Emergency Contact

Work - Education - Certifications

Uniform Information

Internship Schedule Request

Other Information

Registration