1-Day Enrollment

1-Day EFDA & Radiology Enrollment

Dental Assisting Academy of the Palm Beaches 1-Day Enrollment Application for the EFDA or Dental Radiology Course. You only need ONE application if you are taking BOTH classes on the SAME day. Please be advised: Once you have confirmed your spot with the Academy, an ADDITIONAL $100 fee will be applied if you cancel or change class dates AFTER confirmation.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
Date of Birth*

MonthDayYear
Name of Emergency Contact*

First NameLast Name
Emergency Conctact Phone#*

Area CodePhone Number
What date did you want to start the course/courses? If you're not sure, please refer to our schedule page*

MonthDayYear
What courses did you want to take? *Select all the apply*

EFDARadiology
EFDA & Radiology are held on select days: When did you want to take the Course(s)?*

April 14th (6 Seats Available)May 12th (6 Seats Available)June 9th (6 Seats Available)
How long have you been a Dental Assistant? *
* If you are a Dentist from another country please state which country you practiced in and what year you have obtained your license *
What is the name of the Dentist that you work for?*
Dental Office Phone Number*

Area CodePhone Number
What name would you like to have PRINTED on your Certifications? Please remember to add middle or other names wanted, and check spellings. *
Will you be needing Language Translation assistance?*

YesNo
*Language Translation assistance will only apply to those students whose primary language is not English for the written mulitple choice examinations for the courses* Google Translate will be provided as an option for assistance.
How did you hear about this class?*

Please answer the following skill questions: *

	Never Performed	Low-Proficiency	Medium-Proficiency	High-Proficiency	Mastered Skill
Dental Impression
Pouring Stone Model
Trimming Stone Model
Coronal Polishing
Tofflemire Matrix
Dental Sealants
Rubber Dental Dam
Cord Packing
Creating Temporary Crown
Trimming Temporary Crown
Cementing & Cleaning Temporary Crown
Manual Blood Pressure & Vital Signs
Dental Radiology

I (student above) agree & understand that an additional $100 will be placed onto the account if a reschedule is requested after confirmation of enrollment from the Academy is completeted. I understand that study materials will be sent after confirmation of enrollment and study answers will only be provided upon completion of quesitions are subitted.
Virtual Signature binds the Student to Terms and Conditions of the Academy*

Clear
Please upload a copy of your Drivers License, Passport, or other issued Government ID *

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Notes & Comments:

Class Enrollment*

Expanded Functions Dental Assisting Course$430.00

Radiology Course$295.00

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Total $0.00

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1-Day EFDA & Radiology Enrollment