enrollment form Dental Assisting Institute Modesto Campus 3300 Tully Rd., Ste A6 Modesto, CA 95350 Tel: (209) 527-0101 Fresno Campus 4832 N. First St., Ste. 105 Fresno, CA 93726 Tel: (559) 588-4900 Course NameCoronal PolishRadiation Safety8 Hour Infection ControlPit and Fissure SealantsRDA Exam Review CourseRDA Exam Home StudyUltrasonic ScalingFirst Name*Middle NameLast Name*Last 4 Digits of Soc. Sec. #*Student Address*Street AddressCity*City *State* State *ZipZIP *Date of Birth* Date Format: MM slash DD slash YYYY Phone#*CellPhoneAdmin RepShellyEmail* Emergency phone #Start DatesRadiation Safety April 19, 2020 ModestoRadiation Safety July 26, 2020 ModestoRadiation Safety October 18, 2020 ModestoStart DatesCoronal Polishing April 11, 2020 ModestoCoronal Polishing July 18, 2020 ModestoCoronal Polishing October 10, 2020 ModestoStart DatesPit and Fissure Sealants February 8,2020 ModestoPit and Fissure Sealants May 9, 2020 ModestoPit and Fissure Sealants August 15, 2020 ModestoPit and Fissure Sealants November 7, 2020 ModestoStart Dates8 Hour Infection Control MODESTO April 4, 2020 Modesto8 Hour Infection Control MODESTO July 11, 2020 Modesto8 Hour Infection Control MODESTO October 3, 2020 Modesto8 Hour Infection Control FRESNO February 29, 2020 FresnoStart DatesUltrasonic Scaling February 9, 2020 ModestoUltrasonic Scaling May 10, 2020 ModestoUltrasonic Scaling August 16, 2020 ModestoUltrasonic Scaling November 8, 2020 ModestoStart DatesRDA Exam Home Study ReviewStart DatesRDA Exam Review Course TOTAL FEES, CHARGES, AND EXPENSES Product Name Price: $0.00 Registration FeeRegistration Fee: $100.00Tuition FeeTuition Fee: $500.00Equipment FeeEquipment Fee: $60.00Registration FeeRegistration Fee: $100.00Tuition FeeTuition Fee: $240Equipment FeeEquipment Fee: $100.00Registration FeeRegistration Fee: $100.00Tuition FeeTuition Fee: $240Equipment FeeEquipment Fee: $100.00Registration FeeRegistration Fee: $100.00Tuition FeeTuition Fee: $350Equipment FeeEquipment Fee: $100.00Registration FeeRegistration Fee: $100.00Tuition FeeTuition Fee: $185Equipment FeeEquipment Fee: $100.00Registration FeeRegistration Fee: $50.00Tuition FeeTuition Fee:Book FeeBook Fee: $100Registration FeeRegistration Fee: $50.00Tuition FeeTuition Fee: $75.00Book FeeBook Fee: $150Total Charges: $0.00 *YOU ARE RESPONSIBLE FOR PAYMENT OF THIS AMOUNT. By signing you understand and acknowledge that you have received and read the current course information and although placement assistance may be provided to you; you recognize that the school cannot promise or guarantee employment or income level to any student or graduate. Dental Assisting Institute does not provide refunds for courses unless the instructor cancels the course. Courses are non-transferable and non-refundable. By signing below, purchaser understands and accepts the policy of Dental Assisting InstituteSignature of Student*Date* Date Format: MM slash DD slash YYYY Signature of Parent or Legal GuardianDate Date Format: MM slash DD slash YYYY Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name
