Fillable Dental Hygiene Application (Diablo Valley College)

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Dental Hygiene Application (Diablo Valley College)

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  • 6 check-boxes
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Diablo Valley College Dental Hygiene Application 2018
Page 1 of 4
Rev: 7/26/2017
Dental Hygiene Application for Fall 2018
Filing Period: January 1 – February 15, 2018 at 5:00 p.m.
Date
Date of Birth
DVC 7 Digit Student ID Number (Required)
Last Name
First Name
Middle
Other Used
Mailing Address
County
State
Zip Code
Home Telephone
Work Telephone
Cell Telephone
Email Address
Have you attended DVC before?
Yes No
If "Yes", what year(s) did you attend
Have you attended another DH program?
Yes No
If "Yes", where and when did you attend, and what was the reason for leaving
Have you applied to the DVC DH Program before?
Yes No
If "Yes", list previous application year(s):
Have you graduated from a dental assisting (DA) program?
Yes No
If "Yes", when:
Please provide proof of graduation from a Dental Assisting program (i.e., certificate awarded, official transcript)
Indicate length of DA program Where did you take this program
Do you have current CDA/RDA Licensure?
Yes No
If "Yes", please provide proof of current CDA/RDA licensure
Please indicate dates of your Registered Dental Hygiene Observations: ___________________ ___________________
Please list the name, starting and ending dates, and any degrees or certificates, for all colleges, technical and vocational schools attended. Also include
colleges in which courses were attempted although they may not have been completed.
Name of College
City and State
Dates Attended
Name and date of degree
awarded; or state “degree in
progress”; or “no degree”
1
2
3
4
5
Applicant's Certification
I hereby certify that I have personally read and completed the above application. I understand the application criteria and procedures for
the
Dental Hygiene Program. I accept complete responsibility for submitting all required official documents. All information provided is true and
accurate.
Signature of Applicant Date of Application
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signature
click to edit
Diablo Valley College Dental Hygiene Application 2018
Page 2 of 4
Rev: 7/26/2017
Worksheet for Associate of Science (AS) Degree in Dental Hygiene
Filing Period: January 1 – February 15, 2018 at 5:00 p.m.
Directions: This form is to be completed by the applicant. Enter the course number, course title, college where the
course was taken, the date (semester) the course was completed. Substitutions for General Education Courses must be
approved by Admissions and Records and are kept on file.
DVC Category/Course
Equivalent
Course #
Course Name
College Where
Course
Was Taken
Date
Completed
Course
Grade
Prerequisites - Sciences (within 7 yrs)
BIOSC 139 Anatomy
BIOSC 140 Physiology
BIOSC 119 or BIOSC 146
Microbiology
CHEM 108 or CHEM 120 or
CHEM 121 Chemistry
CHEM 109 or CHEM 227
Organic/Biochemistry
NUTRI 160 Nutrition
Prerequisites – General Education
ENGL 122
MATH 120 or higher
COMM 120 or
COMM 130
SOCIO 120
PSYCH 101 or
PSYCH 122
Applicant's Certification
I hereby certify that I have personally read and completed the above worksheet. All information provided can be verified by transcripts. I
accept complete responsibility for submitting all required official documents.
Signature
Date
Clear Form
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signature
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Diablo Valley College Dental Hygiene Application 2018
Page 3 of 4
Rev: 7/26/2017
Dental Office Observation Form
Filing Period: January 1 – February 15, 2018 at 5:00 p.m.
The Dental Office Observation Form must be dated between 02/15/17 – 02/15/18
To the Dental Professional:
The Diablo Valley College Dental Hygiene Program requires our prospective dental hygiene students to observe the following
dental related procedures to gain an understanding of dental and dental hygiene practices. We appreciate your time in allowing
students to observe you in your workplace. Our goal is that our applicants will be better informed regarding their chosen career
path. This form must be completed and signed by the dentist/hygienist regardless of employment experience of the prospective
applicant. Two observations are required. Each observation requires a minimum of 3 hours.
Applicant’s Name:
Observation of a Registered Dental Hygienist, not a Dentist, performing an entire recall prophylaxis and/or supportive
periodontal therapy (maintenance) including observation of infection control procedures. The infection control procedures must
include: operatory preparation and post-appointment protocol, cleaning and sterilizing instruments (minimum 3 hours).
RDH License No. (REQUIRED) RDH Signature (REQUIRED)
Date Total Hours
Dentist License No. (REQUIRED) Dentist Signature (REQUIRED)
Date Office Telephone Number
Office Address
Observation of a Registered Dental Hygienist or a Periodontist, not a general Dentist, performing quadrant(s) of periodontal
therapy with local anesthesia on a patient with at least moderate chronic periodontitis (minimum 3 hours).
RDH or Periodontist License No. (REQUIRED) RDH or Periodontist Signature (REQUIRED)
Date Total Hours
Dentist License No. (REQUIRED) Dentist Signature (REQUIRED)
(Dentist License No. and Signature not required if student observed a Periodontist)
Date Office Telephone Number
Office Address
Attach
Dentist’s or
Periodontist’s
Business
Card
Here
REQUIRED
Attach
Dentist’s
Business
Card
Here
REQUIRED
Diablo Valley College Dental Hygiene Application 2018
Page 4 of 4
Rev: 7/26/2017
2018 Dental Hygiene Program Applicant Checklist
Directions: To be completed by applicant and included in application packet. Please use the check boxes below to ensure
that you have included everything in your application packet and that it is complete. Only those pages of the application
packet specified need to be included. We strongly recommend you mail your completed application packet via certified mail,
return receipt requested. Using certified mail will give you the ability to track delivery of your application packet. Please do
not contact the Dental Hygiene Program or the Dental Hygiene Program Coordinator to ask about the status of your
application. All applications are processed and reviewed by Admissions and Records.
Completed application packet is due by February 15, 2018 at 5:00 pm. Please mail to:
Diablo Valley College
Office of Admissions and Records/Dental Hygiene Application
321 Golf Club Road
Pleasant Hill, CA 94523
Applicant Name: ________________________________________________________
(Last Name) (First Name)
Other Name(s) Used:_____________________________________________________
Dental Hygiene Program Applicant Check List
Dental Hygiene Application including applicant’s signature
Worksheet for AS in Dental Hygiene including applicant’s signature
Official, sealed, and unopened transcripts from all colleges and universities attended
reflecting final grades
All transcripts must be included in the application packet even if the transcripts
were sent prior to DVC
Exception: Transcripts are not required for coursework completed at DVC, Contra
Costa or Los Medanos Colleges
Dental Office Observation Form dated between 02/15/17 – 02/15/18
Include a stamped, self-addressed postcard for verification that your application has
been received by DVC – Admissions and Records.
Postcard confirms receipt of application only
It does not confirm eligibility for, or acceptance into, the dental hygiene program
It does not indicate that the application has been submitted correctly
Incomplete applications will not be considered
No notification will be given for incomplete applications
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