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) 777-4146 Course NameCoronal PolishRadiation Safety8 Hour Infection ControlPit and Fissure SealantsUltrasonic 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 November 1, 2020 MODESTOStart DatesCoronal Polishing December 12, 2020 MODESTOStart DatesPit and Fissure Sealants November 8, 2020 FresnoStart Dates8 Hour Infection Control MODESTO December 6, 2020 ModestoStart DatesUltrasonic Scaling November 8, 2020 ModestoUltrasonic Scaling November 22, 2020 FresnoStart DatesRDA Exam Review Course TOTAL FEES, CHARGES, AND EXPENSES 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 Amount for Full Course: $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. Please note the Registration Fee includes both days of class. By signing below, purchaser understands and accepts the policy of Dental Assisting Institute. Signature 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 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Product Name Price: $0.00
