APPLICATION FOR ADMISSION TO THE DENTAL HYGIENE PROGRAM Fall 2016 Please type or print neatly

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1 Application must be received in the Health Science Department not later than February 2, 2016 Date Stamp When Received: HEALTH SCIENCES DEPARTMENT Santa Rosa Junior College 1501 Mendocino Avenue Santa Rosa, California (707) ! (707) Fax APPLICATION FOR ADMISSION TO THE DENTAL HYGIENE PROGRAM Fall 2016 Please type or print neatly Social Security # (last 4 digits) SRJC Student ID# NAME IN FULL: Last First Initial Previous last names that may appear on your records: _ Mailing Address: Street Address City State Zip Code Home Phone:_ Work Phone:_ Cell Phone:_ address: Emergency Contact Person: Emergency Contact Phone:_ It is your responsibility to notify the Health Sciences office in writing Should you have a change of address, phone number or . In accordance with state law, the Dental Hygiene Committee of California may deny licensure for crimes substantially related to the practice of dental hygiene. This includes convictions involving sex crimes, drug crimes (including DUI), and crimes of violence. It is the responsibility of the applicant to present sufficient evidence of rehabilitation to the DHCC prior to licensure application. Upon acceptance into the DH program, any student who has had a conviction related to any of the above should contact the director of the program to discuss the problem, rehabilitation, and whether the DHCC should be notified. Questions that students may have related to possible denial for licensure should be referred to: Dental Hygiene Committee of California, 2005 Evergreen Street Ste. 1050, Sacramento, CA (916)

2 For the application to be processed, all transcripts that have prerequisite courses MUST be included with this application. Apply to the SRJC if not a current student: Submit the following: Unofficial transcripts from Santa Rosa Junior College only Official (sealed) transcripts from colleges other than Santa Rosa Junior College IMPORTANT: To have coursework considered as substitutions for required prerequisites a Course Substitution Request Form (CSF) must be completed and attached to each substituted course with a catalog description and any other qualifying documents such as course syllabus and/or course outline of record: Select Forms to link to CSF List ALL colleges attended beginning with the most current Dates From - To Institution and Address Diploma, Degree or Certificate Date Completed

3 Complete Prerequisites: Applicants for the 2016 program must complete their prerequisite courses by the end of the fall 2015 semester. See requirements for the DH major on Web page for details. See in-progress applicant pool for exception to these criteria. Grades from the science prerequisite courses must average a minimum GPA of 2.7 Grades from the non-science prerequisite courses must average a minimum GPA of 2.5. Selection Process: Please refer to the most current Web page information for the selection process. Additional information about this process may be found by consulting with a Health Science Counselor or the Program Director. Notice: The SRJC Dental Hygiene Program is a recognized major for an Associate Degree in Dental Hygiene. This means if you already have an Associate Degree from another institution, you MUST meet the requirements of SRJC for the Associate Degree in Dental Hygiene. Contact the Counseling Department (707) All students who are graduated from the SRJC Dental Hygiene Program must complete the SRJC degree requirements before they qualify to take the California Dental Hygiene Board or Regional Examinations and the Dental Hygiene National Board Examination. Documents submitted to the Health Sciences Department become the property of the Department and may be disposed of at our discretion. IMPORTANT Have you applied to this program before? " Yes " No If so, when did you apply? Have you even been enrolled in a dental hygiene or dental school program in another institution? " Yes " No Do you have an Associate's degree? " Yes " No Do you have a Bachelor's degree? " Yes " No All applicants will be notified whether or not they have been accepted into the DH program via US mail approximately 6-8 weeks after the application deadline. This information will not be given over the telephone. I certify under penalty of perjury that the statements in this application are true to the best of my knowledge and ability. Falsification of information on this application will be considered grounds for dismissal. Signature of Applicant Date

4 Prerequisite Course Completion Form Dental Hygiene Program This form must be filled out by ALL applicants and turned in by application deadline. Note: Students applying for the In-Progress Applicant Pool may have ONE science OR ONE non-science prerequisite in progress at the time of application: Please refer to the Health Sciences/Dental Programs Web site for further information. Prerequisite Course Name # Units Grade College where Course Completed: Chemistry 60 (or) Semester/year Completed Chemistry 1A and Chemistry 8 Anatomy 1 Physiology 1 Micro. 5, or 60, or HLC 55 Psychology 1A, or 4, or 53 English 1A Speech 1A or 60 or COMM. 5 or 6 Sociology 1, or 2, or 10 or 30 Food & Nutrition 10 or 62 Crit. Thinking (Phil 3 or 5, Spch 3A or 9, or Eng 5) Print Name Signature Date Applying for the in progress pool, please indicate which course is outstanding_ In progress student - Signature

5 For course substitutions from the prerequisite list. IMPORTANT: To have coursework considered as substitutions for required prerequisites a Course Substitution Request Form (CSF) must be completed and attached to each substituted course with a catalog description and any other qualifying documents such as course syllabus and/or course outline of record: Select Forms to link to CSF Associate Degree Requirements Course Completion Form Dental Hygiene Program This form must be filled out by ALL applicants and turned in by application deadline. General Education Requirement A. English Composition English IA Course Name # Units Grade College where Course Completed Semester Completed or WILL BE completed B. Comm & Analytical Thinking Dental Hygiene Prerequisite C. Natural Sciences Dental Hygiene Prerequisite D. Social & Behavioral Sciences Dental Hygiene Prerequisite E. Humanities F. American Institutions G. American Cultures H. Global Perspectives and Environmental Literacy I. Information Literacy Math Competency To determine what classes should be completed to meet the above requirements, consult the Associate Degree General Education Pattern Option A in the Catalog or Schedule of Classes. You should also be working with a Counselor in planning how to complete these classes. Contact the Counseling Department at (707) to make an appointment with a Counselor. Option A: General education requirements are considered fulfilled if you have a Bachelor of Arts (B.A.) or Science degree (B.S.), from a regionally accredited college or university. Check this box if you have fulfilled this requirement.

6 If you have an Associate Degree from another institution, you MUST meet the SRJC requirements for the Associate Degree in Dental Hygiene. Graduates of the SRJC Dental Hygiene program are eligible to take the California Dental Hygiene Board and/or the Western Regional Examination and the Dental Hygiene National Board Examinations. S Drive:/HSBAK/Programs/Dental Programs/DH 2015/DH Application 2016

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