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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 $30 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:

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?

Submit your personal statement

Files must be pdf, doc, or txt format

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Scrub bottom size

Fit:
NormalPetiteTall

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

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