6-Week Website Application

Student Application

Dental Assisting Academy of the Palm Beaches
Est. 2011

Celebrating Over 10 Years of Sucess & New Careers!

6-Week Dental Receptionist & Insurance Coding Program

Please fill out the following demographics about yourself. You will then go on to answer a questionnaire about why you would like to become a member of the Dental Healthcare Team!

We can't wait to have another student become part of our success stories!

♥ DAAPB Team ♥
Full Name of Student*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
example@example.com
Date of Birth *

MonthDayYear
Name of Emergency Contact*

First NameLast Name
Emergency Contact Phone #*

Area CodePhone Number
When would you like to begin in the 6-Week Receptionist & Insurance Program?

January 8th - February 19thMarch 19th - April 30thMay 14th - June 25thOther
All On-Campus Training Sessions are held on Thursdays ONLY from 10am - 3pm!

Dental Assisting Academy of the Palm Beaches Assessment

Please answer the following questions to complete the DAAPB Assessment. Did you know: 99% of our students get accepted, 98% graduate and 97% find their dental dream careers & homes!
Why do you want to be a member of the Dental Healthcare Team?*
What do you already know about the job as a dental receptionist?*
What do you hope to gain & accomplish by becoming a dental receptionist? *
What qualities & traits do you have that you think will make you an asset in the dental field? *
Will you be able to manage your time with your current schedule and the course?*
What do you think is a good starting hourly pay for a dental receptionist?*
What does the ideal dental receptionist look like to you?*
What is your Instagram Name?! We would love to follow you!
What is your current employment? *
What shifts at work do you take?*

Opening/Morning ShiftClosing/Night ShiftI make my own schedule
Are you fluent in any other languages? Please select all that apply
How did you hear about Dental Assisting Academy? If you were referred to us, please let us know by who! *
Do you have a minimum of a High School Diploma or GED? *International Degrees are accepted*

YesNo
Please Note: Students who DO NOT have a High School Diploma or GED are subject to take an Entry Exam (Aptitude Test) to determine eligibility into the Program.
Please Upload a recent photo of yourself. Smile!*

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Notes or Comments for Miss Kennedy
Would you like to be sent your custom most current interest-free payment plan options?

Yes please!No thank you.
Please Read:

Choose between these options

1. An Application Fee is necessary for the application. It does not secure your seat in your requested class, it will only send your application!

OR

2. Making a deposit will enroll you in the class of your choice, by immediately securing your spot! The Application Fee is included in the Deposit. This will ensure your spot is safe!
1. Application Fee $30.00
2. Deposit Fee $600
3. Full Class Tuition $4600
*The Application Fee is non-refundable. If the student is not accepted into the program and a Deposit Fee is made a refund of $570 (Application Fee deducted) will be given on original payment method. *All enrollments regardless of payment choices are still under the admissions committee review until accepted into the program. *Be selecting Option 2 ($600 Deposit Fee) you do not have to pay the Application Fee, all monies paid will be credited towards tuition*
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Student Application

Dental Assisting Academy of the Palm Beaches Assessment