Fill - Free fillable Pasadena City College - Dental Hygiene Application PDF form

Pasadena City College Dental Hygiene Application

NOTIFICATION letters will be sent to applicants by EMAIL only and information will be given regarding the next

steps. Placement on the alternate list does not guarantee acceptance for the following year. All alternates who are

not accepted into the program must reapply. Enrollment is determined using the point scoring system. Additionally,

acceptance into the program may also be based on the outcome of a criminal background check. All applicants must

have an overall GPA of 3.0 or better in the prerequisite courses in order to be considered for acceptance into the

dental hygiene program. A “C” is the minimum course grade necessary to meet a prerequisite. Priority will be given

to those who have all prerequisite courses completed at the time of application. Applicants with incomplete

coursework at the time of application will only be considered once proof of completion is provided.

Filing Period: February 1

st

– April 1

st

Date

Last Name

First Name

Middle

Date of Birth

Social Security Number:

XXX-XX- ____ ____ ____ ____

PCC ID (if applicable)

Mailing Address

City

State

Zip Code

Email Address (Students will only be notified of their status by email. Please print

clearly)

Home Phone #

Cell Phone #

Have you previously applied to the Dental Hygiene Program: If yes (include

semester & year)

Name used on prior application

Are you a U.S. Veteran?

If yes, please submit a copy of your DD214 with this

application

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. One Official transcript must be submitted with this application. A second official transcript

of ALL colleges attended must be sent to the RECORDS OFFICE upon acceptance to the program.

Name of College

City and State

Dates Attended

Name and date of degree

awarded; or state “degree

in progress”; or “no

degree”

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

requesting all required official documents. All information provided is true and accurate.

Signature of Applicant Date of Application

Section A: Program Prerequisites Courses

All prerequisite courses must be completed prior to applying. Students with work in

progress will only be considered once verification of completion is provided.

.

Course

College

Course Title & #

Units

Grade

Term/Year

Chemistry 1A or 2A

Chemistry 1B or 2B

Microbiology 2

Anatomy 25

Physiology 1

Nutrition 11

English 1A

Psychology 1

Sociology 1

Speech 1 or 10

Intermediate Algebra

Humanities

*American Institutions 125

Political Science 1

U.S. History

Physical Activity

*Prerequisite GPA

*American Institutions 125 or US History (one course) and Political Science (one course)

EXAMPLE FOR CALCULATING YOUR GPA

The GPA calculations are based on a FOUR point (4.0) grading scale

Point values for grades earned:

A = 4 points

B = 3 points

C = 2 points

D & F do not qualify

2

Units

Grade

Points

5

A Chemistry

20

5

C Chemistry

10

5

C Microbiology 2

10

4

A Anatomy 25

16

5

B Physiology 1

15

3

B Nutrition 11

9

Total Units = 27

Total Points = 80

Total Points Divided by Total Units = 2.96 (Science GPA)

Multiply the number of units by the grade points for total (5 units X 4 (grade is A) = 20

We do not round up or down for the GPA. Example: 80 ÷ 27 = 2.96. The GPA will be recorded as 2.96 not 3.0.

Be sure to include ALL the prerequisite courses when calculating your prerequisite GPA.

If a course has been taken more than once, the highest grade for that course will be used to calculate the GPA.

Section B: Estimated points for Prerequisite GPA

Maximum Points = 6

GPA

Points Possible

Points

4.0 – 3.67

6

3.66 – 3.34

4

3.33 – 3.0

2

Section C: Estimated points for Specific Prerequisite Courses

Maximum Points = 42; A = 6, B = 4, C = 2

Course Title

College Name

Term & Year

Course Grade

Points

Chemistry 1A or 2A

Chemistry 1B or 2B

Microbiology 2

Anatomy 25 or Physiology 2A

Physiology 1 or Physiology 2B

Nutrition 11

English 1A

Section D: Estimated points for Dental Related Education/License

(One Category only; Maximum points = 4)

Please submit copy of current license and official transcripts to verify information

Educational Licenses

Points Possible

Points Earned

Active Current RDAEF license

4

Active Current RDA license

3

Active Current dental lab tech license

2

Currently enrolled in Accredited CA RDA Program

1

3

_________________________________________________________ _______________________________________

Section E: Estimated points for Dental Related Work Experience.

Full-time is 32+ hours per week (Circle One) Maximum points = 4

Please submit letter from employer to verify information

Time Worked

Full-time Points

Part-time Points

Points earned

Five or more years

4

2

Three to Five years

3

1.5

One to Three Years

2

1

Six months to One year

1

0.5

Section F: Estimated points for Observation of Licensed Registered

Dental Hygienist

It is recommended that you observe a dental hygienist in two different practice settings/offices. Points will be

awarded for confirmed observations. Use the log format provided for verifying information. Maximum Points = 3

Observation Hours Points

Points earned

18 3

12 2

6 1

Section G: Calculate your ESTIMATED POINTS by transferring your

points from each section and total them. Maximum Points = 59

Section

Total Possible Points

Applicants Points

Section A

All prerequisites completed;

Overall 3.0 GPA or higher

*****************

Section B

6

Section C

42

Section D

4

Section E

4

Section F

3

Total

59

NOTE: When adding up your points, be sure to include all sections that apply to your total. Actual GPA and points

will be determined by PCC Dental Hygiene Program admissions. In the event when multiple applicants have the

same score the order of placement on the acceptance or alternate list will be completed by random selection.

The dental hygiene program takes two years to complete once you are accepted into the program.

I certify that all information on this application is correct to the best of my knowledge. I understand that any falsification

And/or withholding of information will disqualify this application.

Applicants Signature Date

4

click to sign

signature

click to edit

______________________________________________________________________________

Dental Office Observation Form

To the Dental Professional:

The Pasadena City College Dental Hygiene Program requires our prospective dental hygiene

students to observe dental procedures to gain an understanding of 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.

Applicant’s Name:

Observation of a Registered Dental Hygienist, not a Dentist. Please attach business

card or letter regarding observed hours.

RDH License No.

RDH Signature

Date

Total Hours

Office Address

Office Telephone Number

RDH License No.

RDH Signature

Date

Total Hours

Office Address

Office Telephone Number

RDH License No.

RDH Signature

Date

Total Hours

Office Address

Office Telephone Number

5

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