Upcoming Classes Spring 2025: Starts Saturday, March 1st, 2025 STEP #1 - Don't Miss Out! Spots Are Filling Up Quickly! "*" indicates required fields Which location would you like to attend class?*SelectPennsylvaniaHow did you hear about us?*SelectOnline SearchReferred from a FriendDental OfficeFunding SourceFirst Name* Last Name* Email* Phone*Session*SelectSpring 2025: Saturday, March 1Summer 2025: Saturday, June 7Fall 2025: Saturday, September 6Location*SelectBala Cynwid, PALocation*SelectBala Cynwid, PALocation*SelectBala Cynwid, PALocation*SelectBala Cynwid, PAProgram Type*SelectClinicalProgram Type*SelectCPR ClassPayment Options*SelectOption 1: -$125.00 due with the registration form -$3,370.00 is due on or before the first day of classOption 2: -$125 due with the registration form -5 x $709 due every other Monday the week of classOption 3: -$125 due with the registration form -$1,000 due by enrollment -5 x $509 due every other Monday the week of classPayment Options*SelectOption 1: -$125.00 due with the registration form -$3,370.00 is due on or before the first day of classOption 2: -$125 due with the registration form -5 x $709 due every other Monday the week of classOption 3: -$125 due with the registration form -$1,000 due by enrollment -5 x $509 due every other Monday the week of classPayment Options*SelectOption #1 -$125.00 due with the registration form -$3,160.00 due before the start of class on the first day -TOTAL $3,790OPTION #2 -$125.00 due with the registration form - 5 X $793.00 biweekly payments due on or before the start of the last session -TOTAL $4,090OPTION #3 --$125.00 due with registration form -$1,000 down due with the registration form - 5 X $593.00 biweekly payments due on or before the start of the last session -TOTAL $4,090Registration Fee* Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeRegistration Fee* Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeRegistration Fee* Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feePayment Information* Card Number Month010203040506070809101112 Expiration Month Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Expiration Year Security Code Address* 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 Concent* 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.NameThis field is for validation purposes and should be left unchanged.
