1505 Dillingham Blvd. Suite 210
Honolulu, Hawaii 96817
(808) 428-4747
Application for Dental Assisting Program
Term Start: ______Completion Date: ______
Applicant Section
Applicant Name: Last: ______First: ______Middle: ______
Birthdate: ______Gender: ____ (F) ____ (M)SSN: ______
Home Address: ______
City, State, Zip: ______
Contact Information: Home# ( ) ______Mobile ( ) ______
E-mail Address: ______
______
Parent/Guardian Section
Parent/Guardian Name: ______
Home Address: ______
City, State, Zip: ______
Contact Information: Home# ( ) ______Mobile ( ) ______
E-mail Address: ______
Please complete one section:
□ I graduated from high school in theyear ______
Name of high school ______
Address ______City/State ______
Name at time of graduation ______
□ I passed a GED exam in the year ______
Name of GED testing center ______
Address ______City/State ______
Name at time of exam ______
□ I passed a High School Equivalency exam in the year ______City/State ______
Name at time of exam ______
□ I am not required to provide POG because I previously attended college
Name of College or University ______
Description of Course______
City/State ______
Program Director Section
Please submit the transcripts, diploma, GED certificate and other credentials as required by HDAA.
Name of the Program Director: ______
I will submit the required information by the due date. YesNo
If No, please explain ______
Signature Section
I hereby attest that the above information is true and correct and acknowledge that acceptance into this academy will be bases, in part on the validation of this information. I also authorize the release of the above information to a third party for the purpose of either verifying the information or obtaining a copy of my high school or equivalency documentation.
Signature of Student: ______Date: ______
Signature of Parent/Guardian ______Date: ______
Signature of Director ______Date______
Thank you. When completed, please return this form to the academy.