Upcoming Classes Fall 2023: Starts Saturday, September 2nd, 2023 STEP #1 - Don't Miss Out! Spots Are Filling Up Quickly! Name(Required) First Last Email(Required) Phone(Required)How Did You Hear About UsReffered From a FriendOnline SearchDental OfficeMedical OfficeFunding SourceProgram(s) You Are Applying For(Required) Dental Assisting Dental Administrative Medical Assisting STNA CPR How many classes are you enrolling in?Dental Assisting Registration Information StateOhioArizonaLocationHillardSpringColerainKenwoodWest ChesterEastgateLocationGoodyearSessionSpringSummerFallWinterLearning StyleHybridPayment OptionOption 1 - Pay In Full By First Day of ClassOption 2 - Biweekly PaymentsOption 3 - $1,000 Down, Bi Weekly PaymentsDental Administrative Registration Information StateOhioLocationWest ChesterSessionSpringSummerFallWinterLearning StyleHybridPayment OptionOption 1 - Pay In Full By First Day of ClassOption 2 - Biweekly PaymentsOption 3 - $1,000 Down, Bi Weekly PaymentsMedical Assisting Registration Information StateOhioArizonaLocationWest ChesterLocationOnline OnlySessionSpringSummerFallWinterLearning StyleHybridPayment OptionOption 1 - Pay In Full By First Day of ClassOption 2 - Biweekly PaymentsOption 3 - $1,000 Down, Bi Weekly PaymentsRegistration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeRegistration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeRegistration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeRegistration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeRegistration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feePaytrace Card Number Month010203040506070809101112 Expiration Month Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Expiration Year Security Code Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Consent(Required) By checking this box, you are agreeing to the authorization. I hereby authorize The Dental Assistant Academy to initiate ACH debits to my bank account. I understand I may revoke this authorization by calling Katie Dougherty @ 513-855-5100 or emailing Katie@dentalassistantacademy.com within 3 business days prior to the authorized processing date. All transactions and refunds are handled on a case-by-case basis. Please contact Dental Assistant Academy if you have questions or concerns regarding any transaction or refund.
