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
Gender *

Male Female

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 Date Picker Icon
Name of Emergency Contact *

First Name Last Name
Emergency Contact Phone # *

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

Month Day Year Date Picker Icon
What date did you want to start the course? *

Tuesday, March 10th-May 5th Wednesday, January 29th- March 18th Thursday, February 13th-April 9th Saturday, March 21st-May 23rd I'm not sure yet!
By my signature below, I verify that I have read and agreed to the Student Enrollment Agreement.

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Dental Assisting Academy of the Palm Beaches Assessment

Please answer the following questions to complete the DAAPB Assessment
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 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! *
What was your High School GPA? *
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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Please Read:

Choose between these two options

1. An Application Fee is necessary for the application.

2. Making a deposit will enroll you in the class of your choice. The Application Fee is included in the Deposit. This will ensure your spot is safe!
1. Application Fee $25.00
2. Deposit Fee $600.00
*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 ($600.00 Deposit Fee) you do not have to pay the Application Fee, all monies paid will be credited towards tuition
Options: *

Application Fee $ 25.00

Class Deposit $ 600.00

Total $ 0.00
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Student Enrollment Application

Dental Assisting Academy of the Palm Beaches Assessment