Dental Hygiene Program -Application

Dental Hygiene Program -

Application

Albany State University

Darton College of Health Professions

c/o Dental Hygiene Program

2400 Gillionville Road

Albany, GA 31707

CONTACT INFORMATION

Last Name:*

First Name:*

Middle Initial:

Preferred Name (if different):

Current Street Address, Apartment Number, or P.O. Box:*

City:*

State:*

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Zip Code:*

Permanent Street Address, Apartment Number, or P.O. Box:*

City:*

State:*

Select

Zip Code:*

E-mail (please provide the one most frequently checked):*

Cell Phone Number:*

ASU Ram ID #:

(Optional)

EDUCATIONAL BACKGROUND

High School Name:*

City:*

State:*

Select

Date of Graduation or GED:*

1) College/University Name:*

City:*

State:*

Select

Date (Start):*

Date (End):*

Degree and Major (if applicable):*

Degree Received?*

Yes

No

2) College/University Name:

City:

State:

Select

Date (Start):

Date (End):

Degree and Major (if applicable):

Degree Received?

Yes

No

3) College/University Name:

City:

State:

Select

Date (Start):

Date (End):

Degree and Major (if applicable):

Degree Received?

Yes

No

OBSERVATIONAL HOURS

A minimum of 16 hours must be completed before June 1 in two separate general dentistry offices/facilities. Please summarize your observational hours as indicated below. Be sure to include the verified/signed documentation of hours with the application. You should observe in professional attire and professional conduct. Observation hours are considered applicable for a period of 2 years.

1) Name of Facility/Office:

Facility/Office Location (City and State):

Number of Hours in EACH Setting (be specific):

Select

2) Name of Facility/Office:

Facility/Office Location (City and State):

Number of Hours in EACH Setting (be specific):

Select

3) Name of Facility/Office:

Facility/Office Location (City and State):

Number of Hours in EACH Setting (be specific):

Select

4) Name of Facility/Office:

Facility/Office Location (City and State):

Number of Hours in EACH Setting (be specific):

Select

5) Name of Facility/Office:

Facility/Office Location (City and State):

Number of Hours in EACH Setting (be specific):

Select

TOTAL OBSERVATIONAL HOURS:

Select

Required Documents Upload

PLEASE USE THIS SECTION TO ATTACH THE FOLLOWING REQUIRED DOCUMENTS:

Please be sure to attach and upload the following forms listed below. Your application process may be delayed if these forms are not attached!

Observation Hours Form (minimum 16 hours required)

• The Observational Hours Form within this packet is required. It must be signed by a dentist or registered dental hygienist in the facility.

• All hours must be completed prior to the application deadline of June 1.

TEAS Score Report

• Include an unofficial copy of your TEAS Score Report.

• TEAS information can be found in the “TEAS Information” section of this application.

Hand-Written Essay (Word / PDF document acceptable)

• No specific length is required.

Copy of Unofficial Transcripts (if other than ASU)

File Upload:*

Drag and drop files here or

Observation Hours Form Attached?*

TEAS Score Report Attached?*

Hand-Written Essay Attached?*

Copy of Unofficial Transcripts (if other than ASU) Attached?

LETTER OF ACKNOWLEDGEMENT OF DHYG ADMISSION ORIENTATION

In the case that I, (your name), am accepted into the Dental Hygiene Program beginning Fall Semester (indicated below), I understand that my attendance of the mandatory Dental Hygiene Admission Orientation is necessary to keep my seat in the program.

This orientation will be held during late summer, before fall classes begin. It will be help via Webex and is mandatory that I attend this session. I understand that if I do not attend or view this orientation, then my seat in the program will be forfeited. I understand that this orientation is only intended for me, my parents, financial supporters of my education, and/or spouse. Specific details of time, date, and location will be announced when and if I am accepted.

By signing this Letter of Acknowledgement, I agree that I have read the ASU Dental Hygiene Application and agree with the criteria stated within the application.

Fall Semester:*

Fall 2025

Fall 2026

Fall 2027

Fall 2028

Signature:*

Please type in your First and Last Name.

Date of Acknowledgement:*

SIGNATURE

Have you previously applied to the ASU/Darton State College DHYG program?*

Yes

No

If yes, when?

Applicant’s Signature:*

Please type in your First and Last Name.

Signature Date:*

Personal Identifiable Information (PII) Notice:

All personal data and special categories of sensitive personal data collected or processed by Albany State University (ASU) must comply with the ASU Cybersecurity Program Plan, as authorized by the Board of Regents Policy Manual Section 10.4 Cybersecurity:

https://www.usg.edu/policies

Anyone suspecting his or her sensitive personal data has been exposed to unauthorized access, report your suspicion to:

LegalAffairs@asurams.edu

Otherwise, questions concerning GDPR can be forwarded to LegalAffairs@asurams.edu. Typing your name in the box below and submission of this application provides consent to and acknowledgment of the ASU Data Security and Privacy Policy.

Please check the box below to indicate that you have read and understood the PII policy above.

Personal Identifiable Information (PII) Consent:*

Send me a copy of my responses

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