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Registration Form

Fill out the online application fields below.
You must attach a personal statement about your interest in this program and the dental field.
*A non-refundable $75 application fee must be submitted with the student registration.

ALL AREAS MUST BE COMPLETED

Personal Information:

Full Name

Address:

City:

State:

Zip Code:

Age:

DOB:

Sex (Male/Female):

Best contact number:

Email:

Education:

High School:

Award type:

College:

Award type:

Other:

Award type:

Job History:

Company:

Phone:

Date Started:

Date End:

Company:

Phone:

Date Started:

Date End:

Personal Reference (no relatives):

Name:

Phone:

Relationship:

Name:

Phone:

Relationship:

Class Date:

Tuition:

What form of payment will you choose to cover tuition: (Please note, tuition must be paid in full before start of class)

How did you hear about DASGA? (Facebook, Google, Word of mouth, office flyer etc.)

Submit your personal statement

Files must be pdf, doc, or txt format

Scrub top size

Scrub bottom size

Fit:
NormalPetiteTall

Required for uniform, SCRUBS RUN BIG, CHOOSE 1 SIZE SMALLER THAN USUAL SIZE

Answer this simple Question
2 + 2

You will be redirected to submit your $75 application fee via paypal.com