Dental Assisting Program

Enrollment Application

Name

Current Address

City

State

Zip

Permanent Address

City

State

Zip

Social Security (#)

Date of Birth

Diploma or GED

Diploma GED

Year of Graduation or GED

High School Address

City

State

Zip

Have you attended a College or Technical Institution

Yes No

Graduated?

Yes No

2 or 4 Years Degree?

Yes No

Name of College

College Address

Date of Graduation

How I first heard about this program

In case of emergency, contact:

Name

Phone

Relationship

Address

City

State

Zip

Note: Documentation of graduation or GED is required. Please bring a copy to your first class

Contact

11034 Military Drive W,
San Antonio, TX 78251

(210) 571-1101

Mon-Thur: 8:00 a.m - 2:00 p.m

contact@excelhealthcareers.com

Classes

Fri: 8:00 a.m - 5:00 p.m

Sat: 8:00 a.m - 5:00 p.m

Important Links

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