Enrollment Application "*" indicates required fields Step 1 of 8 12% Application for Admission Professional Dental Assistant School 606 West Avenue – Norwalk, CT 06850 Phone: 203-939-9200Name* First Last Email* Date of Birth* Address* City* State*SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code* Cell Phone* Preferred method of contactPreferred method of contact* Email Cell Phone Level of education at the start of your programLevel of education at the start of your program* High School GED College/Technical Institute School Name* Graduation Year* City StateSelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingName of College* Graduation Year* Degree How many years? Graduation Year* Emergency ContactName* First Last Phone*Relationship* How did you hear about us?How did you hear about us?* Google Facebook School Newspaper Friends / Family Member Mailer Other Referral Name Choose SessionLocation / Year / Session* Year20222023 Session Start Date* End Date* Employment Conditions: Ability to speak, read, write English Work and stand for long hours Good manual dexterity with both hands  A background check may be required by dentist employer Non-Discrimination: Professional Dental Assistant School does not and shall not discriminate on the basis of race, color, national origin, sex, sexual orientation, age, religion, marital status or military status in the administration of its admissions or educational policies, scholarship program or in employment does not and shall not discriminate on the basis of race, color, national origin, sex, sexual orientation, age, religion, marital status or military status in the administration of its admissions or educational policies, scholarship program or in employment. The student will bring the following documents on his first day at the Professional Dental Assistant School: Completed/Signed Application Copy of High School Diploma or GED Certificate Copy of Driver’s License or State ID Non-refundable Application Fee ($50) Please upload a copy of your High School DiplomaAccepted file types: pdf, png, jpg, jpeg, gif, Max. file size: 256 MB.If not possible today you can do it in the future, but must be done before you are officially enrolled.Please upload a copy of your Driver's License / IDAccepted file types: pdf, png, jpg, jpeg, gif, Max. file size: 256 MB.If not possible today you can do it in the future, but must be done before you are officially enrolled.Student's Name* Student's Signature* Day*Firstsecondthirdfourthfifthsixthseventheighthninthtentheleventhtwelfththirteenthfourteenthfifteenthsixteenthseventeentheighteenthnineteenthtwentiethtwenty-firsttwenty-secondtwenty-thirdtwenty-fourthtwenty-fifthtwenty-sixthtwenty-seventhtwenty-eighthtwenty-ninththirtieththirty-firstMonth*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear* HiddenSchool Signature Signature EmailThis field is for validation purposes and should be left unchanged. Δ