Returning Pierce College Applicants OR New Pierce College Applicants (currently enrolled Pierce College students proceed to STEP 1)

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1 Dental Hygiene Application Packet Pierce College Dental Hygiene Application for Fall 2012 Admission Consideration Due: Thursday, January 26, 2012 by 3:00 PM Page 1 of Application Directions: Returning Pierce College Applicants OR New Pierce College Applicants (currently enrolled Pierce College students proceed to STEP 1) Please submit admissions form to Pierce College and pay the current non-refundable Admissions Fee for new or returning students (those who have not attended for four or more consecutive quarters) online at: You may now proceed to STEP 1. Please include a copy of your proof of payment when you submit your Dental Hygiene Application. STEP 1: APPLICATION PACKET - Download the FIVE Dental Hygiene Application Packet Forms: a. Dental Hygiene Program Application and Checklist b. Proof of Payment Form c. Education Course Plan Form d. Observation Hours Form e. Extracurricular Form STEP 2: PROOF OF PAYMENT FORM- (Must Be Completed Before Submitting Your Dental Hygiene Application Packet) Fill out the Proof of Payment Form and include one of the following methods of payment for the non-refundable Program Application Fee: Check or Money Order in the amount of $40.00 or provide your Credit/Debit Card information on the proof of payment form and your card will be billed $ DO NOT SEND CASH. Submit to: Dental Hygiene Application Attn: Cashiers Office 9401 Farwest Drive Lakewood, WA The Proof of Payment Form along with the $40.00 must be paid PRIOR to submitting your Dental Hygiene Application Packet. Be sure to allow plenty of time for the Cashier s Office to process your payment. **NOTE** Include a copy of your payment receipt in your application packet! STEP 3: DENTAL HYGIENE APPLICATION & CHECKLIST - Fill out this form completely and be sure to check each required document that you are submitting. Your signature indicates that you have completed and turned in all required documents for the Dental Hygiene Application Packet.

2 13 Application Packet Page 2 of 10 STEP 4: EDUCATION COURSE PLAN FORM - Fill out this form completely. Please see the Application Academic Requirements to be sure you are eligible to apply first. Take all the Science, Math and ENGL 103 (or ENGL&102) courses within the past 5 years. Application Academic Requirements CHEM&121, ENGL 103 or ENGL&102, THREE of the six total science &/or math courses, plus ONE of the three non-science courses must be completed by the end of Fall quarter prior to the Fall quarter admission. For 2012 application year, it would be end of Fall Quarter **NOTE** ALL of the Pre-dental Hygiene courses must be complete by the end of the Spring quarter for the following Fall admission. For 2012 application year, it is June Please complete the entire form by including the courses you intend to take in both winter and spring 2012, just leave the GPA area blank. All other sections must be complete or it will INVALIDATE your application! All science, math and English courses must be five (5) years current, completed during or after January All other courses have no time limitation. **NOTE** Due to course schedule changes, we do allow Education Course Plan changes, BUT you must inform the Admissions Office of your changes in writing by the 5 th day of the quarter that has been changed, otherwise, your application will be INVALIDATED. STEP 5: OFFICIAL TRANSCRIPTS - Request official transcripts from ALL colleges you have attended. Only official transcripts will be accepted. Your official transcripts need to be included with your Dental Hygiene Application Packet. All transcripts must be official, sealed and WITH the Application Packet. Current or Former Pierce College student? YES, Complete the Transcript Request Form and include with your Dental Hygiene Application Packet. You can get a copy of the transcript form at: STEP 6: OBSERVATION HOURS - Include in your Application Packet. If you are a re-applicant and would like to use your forms from the 2011 or 2010 application year, please indicate on the Dental Hygiene Application Form. All Observations must be five (5) years current. Observe a Licensed Dental Hygienist performing the Initial Scaling & Root Planing, Local Anesthesia, Adult Prophylaxis, and Infection Control Procedures. You may observe either a Licensed Dental Hygienist or a Licensed Dentist for the Amalgam and Composite Procedures. Please be sure that you observe a TOTAL OF 16 HOURS, NOT merely the minimums for each area. **NOTE** You will need to observe some procedures more that the minimum required hours listed to get the 16 Total Hours.

3 14 Application Packet Page 3 of 10 STEP 7: EXTRACURRICULAR ACTIVITIES - Extracurricular activities include volunteer work, job, sport, church, or other community service activity. Please see the Extracurricular Form for more examples. Being a part of a social group, like BUNKO, Book Clubs, Quilting, etc. typically will not count. These are social gatherings and not considered volunteer work or activities. Activities that do not last a whole year (ie. sports) may be combined to show a year commitment. We rate TWO areas: a. People contact showing compassion and communication ability, and b. Ability to participate in an extracurricular activity while taking Pre-dental Hygiene courses. STEP 8: COURSE EQUIVALENCIES - If you attend another college/university in WA state, please refer to our TRANSFER GUIDE to see if your college is listed and to determine what courses will automatically transfer to Pierce College for Dental Hygiene Admission consideration. Pierce College Dental Hygiene uses the Eastern Washington University Transfer Guide (EWUTG) to determine course eligibility. Please visit their website at: If your college is not listed on our TRANSFER GUIDE, please work with your college advisor to help you determine which courses might be eligible for transfer acceptance. Then use our online COURSE EXCEPTIONS FORM to submit your course requests for transferability. ONLY THE DENTAL HYGIENE PROGRAM DIRECTOR is authorized to determine course transfers. If you have questions, please contact her directly. Monica L. Hospenthal, RDH, BS, M.Ed. Director, Dental Hygiene mhospent@pierce.ctc.edu Fax: Please be advised that the Transfer Guide is subject to change at any time. If you are concerned about courses transferring, please follow the process as detailed above for substitute course acceptance. Older Transfer Guides are available for your reference. FINAL STEP! Mail or hand deliver to the Admissions Office at the campus your completed Dental Hygiene Application packet. WE MUST BE RECEIVE YOUR COMPLETE packet NO LATER than Thursday, January 26 th by 3:00 PM Dental Hygiene Application Attn: Admissions 9401 Farwest Dr. S.W. Lakewood, WA 98498

4 Application Packet Page 4 of APPLICATION CHECKLIST All Deadlines, Course Requirements, Submissions, etc. are the RESPONSIBILITY of the Applicant. DUE January 26, 2012 by 3:00 PM Thursday If you have submitted your application BEFORE Winter quarter began, please make changes to your EDUCATION COURSE PLAN if applicable by January 13, Please submit a new EDUCATION COURSE PLAN form. Initial Application Packet: Dental Hygiene Program Application Pierce College Admissions Form ITEMS Currently enrolled Pierce College student? New Pierce student submitted electronically? $40.00 Non-refundable Dental Hygiene Application Fee paid in advance (receipt of payment or form) Education Course Plan Form Extracurricular Form Observation Hours Form Official Transcripts from ALL colleges attended (including Pierce College) Submit to the Admissions Office at NO LATER than 3:00 pm on January 26, 2012: Dental Hygiene Application, Admissions Office 9401 Farwest Dr. S.W. Lakewood, WA Space Relations and Writing Sample Tests March 24, 2012, Saturday HSRT by March 23, 2012, Friday April 6, 2012 April 10, 2012 by 4:00 PM Tuesday If your Application is valid, you will be invited to take the Program Admission Tests. The Space Relations and Writing Sample Tests will be taken on March 24, 2012 at Fort Steilacoom. The HSRT test will need to be scheduled to be taken at your convenience either at the Fort Steilacoom campus or an acceptable location. The HSRT test needs to be completed by Friday March 23, Please reserve this date in anticipation of your Application Being valid as these tests are part of the application process and mandatory to remain a valid candidate As applicable: Education Course Plan Changes Official Transcript(s) from Winter Quarter 2012 from ALL colleges attended to Admissions (if any outstanding Pre-dental Hygiene courses taken in Winter Quarter) Required Documentation After Initial Application Packet Submission: All subsequent submissions, unless otherwise noted, must be mailed to: April 27, 2012, Friday Dental Hygiene Application, Attn: Admissions 9401 Farwest Dr. S.W. Lakewood, WA Notification of acceptance status via letter mailed this day!! AFTER ACCEPTANCE! May 11, 2012 Confirm acceptance into the fall class by paying the Non-refundable Advanced Tuition Deposit of $ July 10, 2012 by 4:00 PM Tuesday June through September 2012 September 2012 Official Transcript(s) from Spring Quarter from ALL colleges attended to Admissions, any outstanding Pre-dental Hygiene courses taken in Spring Quarter. Mail to: Dental Hygiene Application, Attn: Admissions 9401 Farwest Dr. S.W. Lakewood, WA Complete all required items which include, but may not be limited to, the medical requirements, Pre-study Packet, etc. Attend the mandatory Dental Hygiene Orientation Week. The entire week prior to the official start of the quarter.

5 Application Packet Page 5 of PIERCE COLLEGE DENTAL HYGIENE PROGRAM APPLICATION FORM DUE: January 26, 2012 by 3:00 PM All Deadlines, Course Requirements, Submissions, etc. are the Sole Responsibility of the Applicant LAST NAME FIRST MIDDLE PREVIOUS NAME SID NUMBER BIRTHDATE ADDRESS (Required) ADDRESS CITY STATE ZIP CELL PHONE HOME PHONE FIRST TIME DENTAL HYGIENE PROGRAM AT PIERCE COLLEGE APPLICANT? YES NO REAPPLICANT TO THE DENTAL HYGIENE PROGRAM AT PIERCE COLLEGE? YES YR NO USE PREVIOUS OBSERVATION HOURS FORM? YES YR NO USE PREVIOUS EXTRA CURRICULAR ACTIVITIES FORM? YES YR NO COLLEGE/UNIVERSITY ATTENDED CITY STATE TRANSCRIPT INCLUDED YES NO COLLEGE/UNIVERSITY ATTENDED CITY STATE TRANSCRIPT INCLUDED YES NO COLLEGE/UNIVERSITY ATTENDED CITY STATE TRANSCRIPT INCLUDED YES NO CHECKLIST: The following items must be included in your Application Packet ANY missing and/or incorrectly completed items invalidate your application! Pierce College Admissions Form (If you are currently enrolled at Pierce College there is no need to submit this form). New students and former students who have been out for 4 or more consecutive quarters, there is a $25 nonrefundable Admission fee that must be paid in addition to the $40.00 Program Application Fee. Dental Hygiene Application and checklist form Receipt for the Dental Hygiene Program Application Fee of $40.00 Dental Hygiene Educational Course Plan Form, PLUS if applicable attach copy of Course Exception Form for classes taken at other colleges and approved by the Dental Hygiene Director. Extracurricular Form Observation Hours Form Sealed Official Transcripts from all colleges attended through Fall Quarter 2011 to be included in Dental Hygiene application packet. (Pierce College students, fill out the Transcript Request Form and submit with your application packet (you can get this form at: By signing below, I verify that the information contained throughout my entire application materials has been provided honestly and to the best of my ability. I understand that the materials I have provided are considered to be my full and complete application to which placement into the Pierce College Dental Hygiene program will be evaluated. SIGNED DATE **NOTE** Completed Application Packets Must be mailed or delivered no later than 3 PM Thursday, January 26, NO POSTMARKS ACCEPTED Dental Hygiene Application, Attn: Admissions 9401 Farwest Dr. S.W. Lakewood, WA 98498

6 Application Packet Page 6 of Pierce College Dental Hygiene PROOF OF PAYMENT FORM Application Fee $40.00 Fill out the Proof of Payment Form and include one of the following methods of payment for the non-refundable Program Application Fee: Check or Money Order in the amount of $40.00 or provide your Credit/Debit Card information on the proof of payment form and your card will be billed $ DO NOT SEND CASH. Dental Hygiene Application, Attn: Cashiers Office 9401 Farwest Drive Lakewood, WA **Note** Please be sure to enclose a copy of your receipt when you submit your Dental Hygiene Application Packet Due: January 26, 2012 NAME: STUDENT ID: / / - / - / / / ADDRESS: street apt # City state zip DAY PHONE: ( ) - CELL PHONE ( ) - ADDRESS: Signature: Payment type (circle one): None Check Money Order Cash VISA Exp. Date: MASTERCARD Exp. Date: Card # Cardholder s Signature: CASHIER CODE FB

7 NAME: Application Packet Page 7 of 10 PIERCE COLLEGE DENTAL HYGIENE EDUCATION COURSE PLAN FORM DUE: January 26, 2012 by 3:00 PM 18 BIRTHDATE: ( mm/dd/yyyy ) PIERCE COLLEGE SID #: You ABSOLUTELY MUST COMPLETE THIS ENTIRE Education Course Plan Form with the Pre-dental Hygiene Courses you have already completed AND the Pre-dental Hygiene Courses you plan to complete in Winter 2012 and Spring 2012 If you have ANY changes to your Education Course Plan, please submit an updated form with the changes by the following deadlines: Pierce College Pre-dental Winter 2012 = January 13, 2012 Spring 2012 = April 6, 2012 Name of College Name of Course & Course # EXAMPLE One Tacoma Community College Inorganic Chemistry, Chem&121 Year & Quarter/Semester Credits Qtr or Sem Repeat Yes/N o Fall 2010, quarter 5 NO 3.8 EXAMPLE Two Washington State University Nutrition, MBIOS 130 Spring 2012, semester 5 NO Leave blank THESE TWO (2) COURSES MUST BE COMPLETE PRIOR TO JANUARY 26, 2012 DEADLINE FOR APPLICATION ELIGIBILITY ENGL 103 CHEM& 121 THREE (3) OF THE FOLLOWING SCIENCES/MATH MUST BE COMPLETE PRIOR TO JANUARY 26, 2012 DEADLINE FOR APPLICATION ELIGIBILITY CHEM& Qtr Credits BIOL& Qtr Credits BIOL& Qtr Credits BIOL& 260 NUTR& 101 MATH& 107 or MATH&146 ONE (1) OF THE FOLLOWING NON-SCIENCE COURSES MUST BE COMPLETE PRIOR TO JANUARY 26, 2012 DEADLINE FOR APPLICATION ELIGIBLITY SOC& 101 PSYC& 100 CMST& 101 GPA

8 Application Packet Page 8 of 10 PIERCE COLLEGE DENTAL HYGIENE EXTRACURRICULAR FORM DUE: January 26, 2012 by 3:00 PM Examples of Extracurricular Activities include, but are not limited to: Dental assisting, dental lab technician, other employment, school and/or team athletics, fine arts, student government, organizations, community/church involvement, study abroad, etc. NAME: DATES OF EMPLOYMENT/VOLUNTEER WORK/ACTIVITY: PIERCE COLLEGE SID #: 19 Directions to Applicant: 1. PRINT this form or this form to the Reference Person(s) who will verify your Extracurricular Activity(ies). You may use up to three (3) Extracurricular Activities to meet this requirement. Be sure to print or send a separate form to each Reference Person. 2. Each activity should coincide with the timeframe that you were enrolled in the Pre-dental Hygiene Courses. 3. Make sure the form is complete prior to submittal including Section Two: The Communication Skills Section. Directions to Reference Person: 1. Please complete Section One. List the major duties, responsibilities or skills the applicant used and needed in this activity. 2. Please complete Section Two. Only check the person(s) and type of communications that this applicant primarily engaged in. For instance, a babysitter would primarily only engage in verbal with children. 3. Sign this form. Your signature verifies that all information on this form is true to the best of your knowledge. Name of Reference Person: Contact Phone Number: Signature: Contact REFERENCE PERSON; COMPLETE THE TWO SECTIONS BELOW and SIGN above. DESCRIPTION ACTIVITY ORGANIZATION EXAMPLE Dental Assisting Dr. Frank Extraction SECTION ONE ROLE/TITLE DUTIES/SKILLS DESCRIPTION Sterilization Technician And Office Assistant Sterilize instruments, Call patients Help Dental hygienist DATE FROM January 2010 DATE TO HOURS PER WEEK Present 5 hours per week SECTION TWO Communication Skills: Please indicate which skills the applicant used during their participation in the above listed activity. Please check all that apply. They must have used these skills at LEAST 50% of the time to qualify: ADULT: TEEN: CHILD: Verbal Writing Verbal Writing Verbal Writing

9 Application Packet Page 9 of 10 PIERCE COLLEGE DENTAL HYGIENE OBSERVATION HOURS FORM Due: January 26, 2012 by 3:00 PM 20 Applicant Name: Birthdate (mm/dd/yyyy): Pierce SID#: Directions: 1. You must observe a Licensed Dental Hygienist for the Initial Scaling & Root Planing, Local Anesthesia, Adult Prophylaxis and Infection Control Procedures. 2. You may observe either a Licensed Dental Hygienist OR a Licensed Dentist for the Amalgam and Composite procedures. 3. Please be sure that you observe a Total of 16 Hours (Two full work days). Minimum hours are given per procedure. 4. **NOTE: You will need to observe one or more procedures more than minimum hours required. RDH, Name Initial Scaling & Root Planing, Local Anesthesia RDH License Number RDH License Expiration Date Practice Location, City/State Dental Practice Phone # Hours Observed Date(s) RDH Signature RDH Name RDH License Number RDH License Expiration Date Dental Practice Location, City/State Dental Practice Phone # Adult Prophylaxis Appointment Hours Observed Minimum 2 hours Date(s) RDH Signature

10 Observation Form Continued RDH Name RDH License Number Application Packet Page 10 of 10 Infection Control Procedures 21 RDH License Expiration Date Dental Practice Location, City/State Dental Practice Phone # Hours Observed Minimum 2 hours Date(s) RDH Signature RDH Name RDH License Number RDH License Expiration Date Dental Practice Location, City/State Dental Practice Phone # Hours Observed Minimum 2 hours Date(s) RDH Signature RDH Name RDH License Number RDH License Expiration Date Dental Practice Location, City/State Dental Practice Phone # Hours Observed Minimum 2 hours Date(s) RDH Signature Amalgam Procedure Composite Procedure Minimum Combined Total Hours Observed: 16 You will need to observe some procedures more than the required minimum hours. Combined Total Observation Hours: (Minimum total of 16 hours)