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Call or Text us: 678-474-6636
info@dasgeorgia.com

    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: First, Middle, Last. ***The name listed will be printed on your certificate, please review carefully for typos

    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?

    Word of mouth referral name or other source -


    Personal Statement:
    No resumes, brief statement about yourself, why you want to become a dental assistant and your career goals.

    Files must be pdf, doc, or txt format

    Uniform

    Scrub Jacket size- You will receive the latter size

    Scrub bottom size

    Fit:

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


    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.
    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

    Acknowledgement

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

    I have read the enrollment requirements and understand the documentation I need to bring in:

    Final Verification Answer this simple question below. Enter numbers only. Do not use letters or symbols.


    • Your application will be automatically submitted once you hit send and you will be redirected to PayPal to submit your $100 application fee.
    • Credit and debit cards are accepted through PayPal. A PayPal account is not required.
    • To pay by cash or check, text 678-474-6636.
    • Applications will not be processed until the application fee has been received.
    • You will receive a confirmation email with next steps.