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.