Dental Assistant Training Program Application

First Name*

Last Name*

Date of Birth*

Phone Number*

Phone

Email*

Address*

City*

State*

Zip Code*

Last four digits of your Social Security Number*

Do you have a High School Diploma/GED?*

Applicants must have either a High School Diploma or GED prior to the start of the program.

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Will you be able to pass a national background check?*

We require a national background check prior to acceptance into the program.

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Will you be able to pass a urine drug screen?*

We require a drug screen prior to acceptance into the program

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Do you acknowledge that the following immunizations are required and you must submit supporting documentation prior to starting the program?*

TB Screening
MMR
Varicella (Chickenpox)
Hepatitis B
Tetanus-Diphtheria-Pertussis (Tdap) Immunization within the past ten years
Influenza

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Personal Statement*

Please tell us about yourself.

Why are you interested in becoming a Dental Assistant?*

Why did you choose the University of Utah Dental Assistant Training Program?*

Will you be able to meet the requirements to complete the online and in-person classes as well as the clinical training?*

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Anticipated Start*

If accepted, how soon will you be able to pay tuition and start the program?

Fall 2025

Spring 2026

Summer 2026

Select your native language:*

English

Spanish

Chinese

Tagalog

Vietnamese

French

Arabic

Korean

Russian

German

Other

Are you proficient in any other languages?

Select all that apply:

English

Spanish

Chinese

Tagalog

Vietnamese

French

Arabic

Korean

Russian

German

Other

None

Please indicate your Race*

Select all that apply:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

Ethnicity*

Hispanic or Latino

Not Hispanic or Latino

Prefer not to answer

Signature*

I certify that the information on this application is true and complete. Further, I understand that consideration for this program may be denied if any information is found to be incomplete or inaccurate.

Send me a copy of my responses

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