Pasadena City College Dental Assisting Program

Transcription

1 Pasadena City College Dental Assisting Program Application for Admission *Answers should be typewritten or printed in ink. Please limit responses to space provided. Student ID if applicable This application is for: Fall Enrollment Date Submitted Spring Enrollment (Limited Classes Available) Name: Last First Middle Address: No. & Street City State Zip Phone # ( ) Cell Phone # ( ) Soc. Sec. # Date of Birth / / Students will only be notified of their status by . Please print clearly Legal Resident of: State Country Citizenship Optional: Ethnicity Background Asian/Pacific Islander African American Caucasian, Non-Hispanic Hispanic Native American Other Gender: M/F Age One official transcript of ALL colleges and high school/ged attended must be submitted with this application. High Schools Attended: School From To GPA GED Diploma (Most recent listed first) Please list City & State Colleges Attended: School From To GPA Degree (Most recent listed first) Please list City & State

2 Are you a U.S Veteran or spouse of a U.S. Veteran? Yes (must provide a copy of DD214) List: Honors or Special Achievements and the year received Have you previously been accepted to a Dental Assisting Program YES / NO_ Have you previously completed any Dental Assisting Program courses at PCC YES/ NO_ If yes, please list school, year of acceptance, and any courses completed: How did you hear about PCC s Dental Assisting Program? (Check all that apply) Through a friend/another dental assistant/dentist PCC Dental Assisting brochure Through a graduate from our program High School Counselor/Career Day PCC Health Careers brochure Advertisement (movie, newspaper etc) Health Sciences Division Office Website Other Indicate any experiences that would demonstrate your ability to work with your hands Indicate any experiences that would demonstrate your ability to work effectively with people Give a summary of your employment history: Will you be employed while attending school? Full time Part Time Position Do you have family care responsibilities? Yes No Financial Aid: Requested financial aid ( ) YES ( ) NO Receiving financial aid ( ) YES ( ) NO Indicate your plans upon graduation from the Dental Assisting Program Private Practice Specialty Practice AS Degree completion Teaching Dental School Dental Hygiene Military Other

3 List extracurricular endeavors, community services, and hobbies in which you have participated Do you have any additional comments that you feel the Admissions Committee should take into consideration when reviewing your application Do you plan on taking the examinations to become licensed as a Registered Dental Assistant ( ) YES ( ) NO Do you plan on taking the examination to become a Certified Dental Assistant (National Certification exam)? ( ) Yes ( ) NO Do you plan on taking the examination to become an Orthodontic Assistant. ( ) Yes ( ) NO Special Statement: This program is approved by the Dental Board of California and is accredited by the Commission on Dental Accreditation of the American Dental Association. Upon successful completion of the curriculum, a student is eligible to take the national written (CDA) exam to obtain the Certified Dental Assistant status and the California State board written and practical (RDA) examinations to obtain the Registered Dental Assistant License. Applicants for RDA licensure are required to submit official fingerprints and undergo a criminal history investigation prior to receiving a license. The law provides for denial of licensure if you have been convicted of certain felonies. Signature Date

4 CHECKLIST The following checklist was designed to assist you in the application process. Please follow it very carefully. Early application is advisable as class is limited. Please check the items below that you have included and/or review the information as stated with this application. Application to the college/financial Aid Complete an application to the college for admission if you are not a current student at PCC. For more information contact (626) and Apply to Financial Aid Application to the Dental Assisting Program Complete an application to the Dental Assisting Program. Applications are accepted during the time periods Please visit Transcripts Send to: Pasadena City College Health Sciences School Office W E. Colorado Blvd. Pasadena, CA One copy of your high school and college transcript must be included with your application Schedule an Appointment Once you have filed both applications and have been accepted by PCC for admission and your transcripts are on file in the Dental Assisting office, schedule an appointment with the program director (626) Registration Upon acceptance into the Dental Assisting Program, you will receive a specific packet with detailed registration information. Be prepared to pay registration fees at time of registration. For more information specific to the registration process contact (626) Blood Borne Pathogens In accordance with standard 5.1 as set forth by the American Dental Association Commission on Dental Accreditation and in an effort to minimize risk to student and staff, we strongly encourage that all students obtain immunization against infectious diseases (mumps, measles, rubella, and hepatitis B). Each student accepted into the program must have completed and returned the PCC Health Clearance form prior to the first day of classes in the Fall Semester. Additional information is available upon request in the DA program office R 508 or the Health Sciences Division office in W 204 Additional Program Cost If accepted into the Dental Assisting program, I understand that there will be additional cost to enrollment in the Dental Assisting Program in additional to tuition, parking, health fee s, etc., that include but not limited to: Instrument kits (Est. $ 1300.) Uniforms (Est. $ 500.) Books (Est. $700) Immunizations/Health Form requirements (est. $ 200) Licensing applications fees (Est. $500), Misc. (Est. $ 200). It is recommended that you apply for financial aid early

5 Skills and Abilities I have reviewed the skills and abilities recommended to be a successful student in the Dental Assisting Program and agree that I will be able to perform the skills and abilities as listed. CPR (Cardiopulmonary Resuscitation) Each Student accepted into the Dental Assisting program must provide proof of and maintain a current CPR/Basic Life Support card. Driver s License/CA identification/student ID Each student accepted into the Dental Assisting program must provide a copy of his or her driver s license or ID and a copy of your current student ID