8-Week Website Enrollment & Assessment

Student Enrollment Application

Dental Assisting Academy of the Palm Beaches
Dental Assisting Academy of the Palm Beaches

8-Week Expanded Functions Dental Assisting Program Application

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 Dental Assistant!

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

♥ DAAPB Team ♥
Full Name of Student *

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 Contact Phone # *

Area Code Phone Number
What date did you want to start the course? *

June 4th-August 13th Afternoon Labs (12:30pm-4:30pm) July 2nd-September 3rd Morning Labs (8am-12pm) August 13th-October 15th Afternoon Labs (12:30pm-4:30pm) September 3rd-November 15th Morning Labs (8:00am-12:00pm)
Class Session Availability:

June 4th: Tuesday (3 Seat Available), Wednesday (4 Seat Available), Thursday (4 Seat Available), Saturday (FULL)

July 2nd: Tuesday (2 Seat Available), Wednesday (4 Seat Available), Thursday (4 Seat Available), Saturday (3 Seat Available)

August 13th: Tuesday (4 Seat Available), Wednesday (4 Seat Available), Thursday (6 Seat Available), Saturday (4 Seat Available)

September 3rd: Tuesday (5 Seat Available), Wednesday (6 Seat Available), Thursday (6 Seat Available), Saturday (6 Seat Available)

*list updated daily*
What day did you want to come for your once a week clinical training lab? *

Tuesday Wednesday Thursday Saturday
By my signature below, I verify that I have read and agreed to the Student Enrollment Agreement.

Clear

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 96% find their dental dream careers & homes!
Why do you want to be a Dental Assistant? *
What do you already know about the job as a dental assistant? *
What do you hope to gain & accomplish by becoming a dental assistant? *
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 assistant? *
What does the ideal dental assistant 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 Shift Closing/Night Shift I make my own schedule
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 *

Yes No
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.
When did you want to come in for a Tour & Enrollment at the Academy? We are open on Tuesday, Wednesday, Thursday & Saturday! *
When did you want to come in for a Tour of the Academy? We are open on Tuesday, Wednesday, Thursday & Saturday! *

Month Day Year
Date
Please Upload a recent photo of yourself. Smile! *

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Notes or Comments for Miss Kennedy
Please Read:

Choose between these two 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!

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 $25.00
2. Deposit Fee $600
3. Full Class Tuition $4200
*The Application Fee is non-refundable. If the student is not accepted into the program and a Deposit Fee is made a refund of $575 (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*
Application Payment Options:
prev next ( X )
Application Fee $ 25.00

Class Deposit $ 600.00

Class Tuition $ 4,200.00

Total $ 0.00
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Student Enrollment Application

Dental Assisting Academy of the Palm Beaches Assessment