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Pre-Enrollment Information

First Name*

Last Name*

Email Address*

Address*

City*

State*

Zip Code*

Primary Phone*

Alternate Phone*

Emergency Contact*

Relationship*

Phone*


Two Character References

1. Name*

1. Relationship*

1. Phone*

2. Name*

2. Relationship*

2. Phone*

Course Information

Desired Upcoming Class*

Referred By*

More Information About Reference

Are you Military or Military Spouse?
YesNo


Medical Information

Medical Allergies

Allergic To Latex?*
NoYes

Medical Conditions

Other Important Medical Information


Education

Highest Level of Education*

Year Graduated / Last Year Attended*


Employment

Most Recent Employer*

Address (inc. city, state, zip)*

Dates Employed*

Phone*

Upcoming Classes

Start Date: September 14, 2020

Monday & Wednesday: 5:15PM – 9:30PM

Start Date: October 12, 2020

Tuesday & Thursday: 5:15PM – 9:30PM

Start Date: November 16, 2020

Monday & Wednesday: 9:00AM – 1:15PM

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Classroom Hours

  • Monday9am - 6pm
  • Tuesday9am - 6pm
  • Wednesday9am - 6pm
  • Thursday9am - 6pm
  • Friday9am - 6pm
  • SaturdayClosed
  • SundayClosed
Instructors

Karen Vess
Founder / Instructor
Karen brings over 42 years of experience and expertise to…
Alisha Tate
Instructor
Alisha is an Expanded Functions Dental Assistant Certified by the…
Sonya Denham
Instructor
Sonya is a Registered Dental Assistant. She has worked as…
Contact Info