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 $100 application fee must be submitted with the student registration.


    ALL AREAS MUST BE COMPLETED



    Personal Information:


    Full Legal Name:


    Street Address:


    City:

    State:

    Zip Code:

    Age:

    DOB:

    Gender:

    Best contact number:

    Email:




    Education:


    High School:

    Award type:
    DiplomaGEDOther

    College:

    Award type:
    DiplomaCertificateDegree

    Other:

    Award type:
    DiplomaCertificateDegree




    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 Enrollment Date:


    Tuition:

    Form of payment towards tuition:



    How did you hear about DASGA?

    Facebook, Instagram, Google, Office flyer, Word of mouth etc. Please include the name of your word of mouth referral

    Word of mouth name or Other source-


    Submit your personal statement


    Files must be pdf, doc, or txt format

    Uniform

    Scrub Jacket size- You will receive the later size

    Scrub bottom size

    Fit:


    SIZING GUIDE: This information is necessary for your uniform, SCRUB PANTS run BIG

    XXS- Numeric 0-1 Bust 31-32 Waist 24-25 Hip 33-34
    XS- Numeric 2-4 Bust 33-34 Waist 24-25 Hip 35-36
    S- Numeric 6-8 Bust 35-36 Waist 26-27 Hip 37-38
    M- Numeric 10-12 Bust 37-39 Waist 28-30 Hip 37-41
    L- Numeric 14-16 Bust 40-43 Waist 31-34 Hip 42-45
    XL- Numeric 18-20 Bust 44-47 Waist 48-51 Hip 52-55
    2XL- Numeric 22-24 Bust 48-51 Waist 43-46 Hip 54-57


    If you are 5'3 or shorter, you are petite.
    If you are 5'4-5'7, you are normal.
    If you are 5'8 or taller, you are tall.


    Acknowledgement

    You must check both boxes in order to submit your application.


    I understand tuition must be paid in full before start of class
    I am aware DASGA does not accept any form of financial aid or scholarship/grants

    I have read the enrollment requirements and understand the documentation I need to bring in (select 1 answer)

    Yes, I am fully aware and have all documents readily available for orientation.No, Please contact me to clarify

    Answer this simple Question. Only input the numeric answer, no symbols.




    You will be redirected to submit your $100 application fee via paypal.com (You can pay with a credit card or debit card if you do not have a paypal account or email admin@dasgeorgia to pay with cash/check in person).
    Once you are redirected to paypal, your registration has been submitted and you will receive a confirmation email.



    [paypalsubmit email:info@dasgeorgia.com itemamount:registration-amount itemname:registration-name quantity:registration-quantity]

    **Please wait 30 seconds to be redirected before hitting the submit button again.

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