Application- Modern Dental Assistant School

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Application

Name

First

Last

Date of Birth

Phone

Alternate Phone

Address

City

State/Province

Zip/Postal

Declaration of Age

I will be age 18 or older by end of session

Resident Eligibility

I am a U.S. citizen

I have a Social Security Number

I have an ITIN with a work permit

Payment Plan

$4500 Payment in full with cash, check or credit/debit card.

$2,500 Down payment prior to the first week of classes and $500 per week for the first 4 weeks of classes, totaling $4500

Payment Information

Weekly payments may be made with Cash, Credit or Debit cards only.

*No interest would be charged with payment plans.

** Students who wish to pay with one of the Modern Dental Assistant School LLC Payment plans must bring the full specified payment to each class and turn it in to the instructor before the class period begins. If a student fails to bring his/her payment to any class period he/she will be asked to leave and will not be allowed to continue with the course. A student who does not bring his/her payment forfeits all deposit and tuition money previously paid to Modern Dental Assistant School LLC , except the amount, if any, that would be due back per the cancellation and refund policy. There is a $50 fee for returned checks.

Student Expectations

Please acknowledge that you will follow/meet the following student expectations.

A valid U.S. Government-Issued photo I.D. or passport prior to class
A U.S. High School transcript (must show completion), equivalency (U.S. college transcripts/degree are also accepted) prior to class
A copy of your shot records to include:
- Hepatitis B
- Tetanus-Diptheria-Pertussis (TDP)
- Measles, Mumps, and Rubella (MMR)
- Varicella
- or signed Vaccination Declination waiver
Transportation to class and externship
Positive and professional attitude
Clean the office at the end of each day
Attendance and timeliness
No cell phone use during class
Access to a computer for weekly homework assignments and reading
Receive, write, and interpret verbal and written communication in English without the assistance of an interpreter
Tattoos/ piercings covered
Hair tied up; well groomed facial hair
Short fingernails

Agree

I understand, acknowledge and agree to follow/meet the student expectations above

I am unable to follow/meet all of the student expectations, please contact me

If you are human, leave this field blank.

Tuition Information

Your $4500 Tuition Includes

Printed study materials and handouts
Training materials and dental supplies
Access to state-of-the art technology
Letter of Recommendation for students that have achieved over 85%
Dental/Orthodontic Assisting Certificate
Clinical Fees

Please note, students are responsible for obtaining their scrubs and gym shoes or clogs to wear in class.

If you have questions, please Contact MoDAS today!