ENROLLMENT
Student Name:
Telephone:
Address:
Email:
Date of Birth:
PROGRAM INFORMATION
The school agrees to provide the following training: Dental Assisting
Start Date:
Completion Date:
Program consists of 13 weeks, 28 classes (103 clock hours), certification for HIV/AIDS, HIPAA, and OSHA, BLS CPR, plus a recommended 100 hour externship (UP TO 150 hour optional externship if student needs more training).
THIS TRAINING WILL COST:
All students enroll for a complete program and pay tuition for the complete program prior to entrance unless other arrangements have been made. Tuition includes books, supplies, and administration fees.
Course
Tuition
Registration Fee
Admin Fee
Books/Supplies
Total
Dental Assisting
$4,550.00
$100.00
$75.00
$675.00
$5,400.00
Total Payment – $5,400.00
The Academy accepts Cash, money orders, and checks. For financial options, please see this link: https://dentalassistantportland.com/payment-plan/
AGREEMENT IS BINDING:
This agreement will be binding only when it has been fully completed, signed, and dated by the student and an authorized representative of the school prior to the time instruction begins.
CHANGES IN THE AGREEMENT:
Any changes in the agreement will not be binding on either the student or the school unless such changes are acknowledged in writing by an authorized representative of the school and by the student or the student’s parent or guardian if he/she is a minor.
OTHER CANCELLATIONS
(Required by WAC 490-105-130) An applicant requesting cancellation more than five days after signing an enrollment agreement and making an initial payment, but prior to entering the school, is entitled to a refund of all monies paid less the $100.00 registration fee.
REFUND AFTER THE COMMENCEMENT OF CLASSES
1. Procedure for withdrawal/withdrawal date:
A. A student choosing to withdraw from the school after the commencement of classes is to provide written notice to the Director of the school. The notice is to indicate the expected last date of attendance and be signed and dated by the student.
2. Tuition charges/refunds:
A. Before the beginning of classes, the student is entitled to a refund of 100% of the tuition less $100.00 registration fee, $75 Admin fee.
TUITION REFUND AFTER COMMENCEMENT OF CLASS
If the student completes this amount of training:
School may keep this percentage of the tuition:
One week or up to 10%, whichever is less
10%
More than one week or 10%, whichever is less, but less than 25%
25%
25% through 50%
50%
More than 50%
100%
Books and Supplies:
There is no refund for any equipment, books and supplies received by the student.
Refunds:
Refunds will be issued within 30 days of the date of student notification, or date of school determination (withdrawn due to absences or other criteria as specified in the school catalog), or in the case of a student not returning from an authorized Leave of Absence (LOA), within 30 days of the date the student was scheduled to return from the LOA and did not return.
Special Cases:
In case of prolonged illness or accident, death in the family, or other circumstances that make it impractical for the student to complete the program, the school may make a settlement which is reasonable and fair (this language optional).
STUDENT ACKNOWLEDGEMENTS:
1. I hereby acknowledge receipt of the Elite Dental Assisting Academy’s school catalog, which contains information describing programs offered, and equipment/supplies provided. The school‘s catalog is included as a part of this enrollment agreement, and I acknowledge that I have received a copy of this catalog.
2. Also, I have carefully read and received an exact copy of this enrollment agreement.
3. I understand that the School may terminate my enrollment if I fail to comply with attendance, academic and financial requirement or if I disrupt the normal activities of the School. While enrolled in the School, I understand that I must maintain Satisfactory Academic Progress as described in the School catalog and that my financial obligation to the School must be paid in full before a certificate may be awarded. Students are expected to conduct themselves in a professional positive manner at all times. Respect, courtesy, and sensitivity are behavioral practices expected among students, instructors, and administrative personnel. Appropriate behavior includes regular and punctual attendance. Students are to conduct themselves in a professional, legal, and cooperative manner that is not disruptive, harassing, intimidating, dangerous to themselves or others, and that does not hinder the progress of other students in the school. A students’ ability to resolve personality conflicts, disagreements with curriculum or teacher presentation, or any matter pertaining to the school, must be handled in a positive manner so as to produce the best possible outcome. Any student who creates, incites, or promotes negativity will be dismissed from the course. Possession of weapons, illegal drugs and alcohol of any kind are not allowed at any time on school property. At the conclusion of each school session, students are expected to maintain classrooms, equipment, and the clinic area at a level comparable to when they started. Any violation of school policies may result in permanent dismissal from school.
4. I also understand that this institution does not guarantee job placement to graduates upon program/course completion or upon graduation.
5. OREGON STUDENTS: Oregon students, or Washington students who wish to work in Oregon state, will be required to sign up, take and pass the DANB written RHS exam prior to graduation. Registration, as required by DANB.org is $75. The state test is $175 ($75 plus $175 =$250 total). Please keep in mind that Oregon State changes their fees often. Elite has no control or affiliation with National or State fees or testing requirements. Students fulfilling an externship in the state of Oregon will be able to place x-rays in a patient’s mouth, under supervision, until they have passed the DANB RHS written exam. After passing the DANB RHS, written exam, a student will then have SIX MONTHS to take x-rays on patients (under supervision), and submit their clinicals to the state of Oregon (clinicals are a full set of x-rays on a patient). As a curtesy, students who graduate from Elite Dental Assisting Academy will have the option of attending an open lab to take a full set of x-rays on a patient (student must provide the patient), if the student is not able to fulfill this obligation through their employer’s office prior to the six-month deadline.
NOTICE TO BUYER:
Do not sign this agreement before you read it or if it contains any blank spaces. This is a legal instrument. All pages of this contract are binding. Read both sides of all pages before signing. You are entitled to an exact copy of the agreement, school catalog, and any other papers you may sign and are required to sign a statement acknowledging receipt of those.
CANCELLATION OF CONTRACT:
If you have not started training, you may cancel this contract by submitting written notice of such cancellation to the school at its address shown on the contract. The notice must be postmarked no later than midnight of the fifth business day (excluding Sundays and holidays) following your signing this contract or the written notice may be personally or otherwise delivered to the school within that time. In event of dispute over timely notice, the burden to prove service rests on the sender.
UNFAIR BUSINESS PRACTICES:
It is an unfair business practice for the school to sell, discount, or otherwise transfer this contract or promissory note without the signed written consent of the student or his/her financial sponsors if he/she is a minor and a written statement notifying all parties that the cancellation and refund policy continues to apply.
CERTIFICATIONS:
I certify that I have read and understand the cancellation and refund policy. It is further understood and agreed that this agreement supersedes all prior or contemporaneous verbal or written agreements and may not be modified without the written agreement of the student and the School Official. I also understand that if I default upon this agreement, I will be responsible for payment of any collection fees or attorney fees incurred by Elite Dental Assisting Academy, LLC. I received a copy of the school catalog; and I am entitled to an exact copy of this Enrollment Agreement, school catalog, and any other papers I sign.
Student Name:
Signature:
Clear
Date:
Parent or Guardian signature required on if under 18 and have passed the required ACT test provided:
Signature:
Clear
Date:
As the authorized representative of Elite Dental Assisting Academy, I hereby agree to the conditions set forth herein: Keri Sork, Executive Student Administrator
REGISTRATION FORM
The Workforce Board (the state agency that regulates this school) requires that we ask you for this information, by law (RCW 28C.10.050). Providing your social security number is voluntary. By law, the information you provide on this form cannot be given out by any state agency as public information. The Workforce Board will not disclose data to anyone except authorized Workforce Board employees or contractors working on specific research activities, who follow strict confidentiality procedures. This format follows the information required to be submitted by the school as part of the annual student data report.
Applicant Name:
Phone:
Address:
City/State/Zip:
Date of Birth (MM/DD/YYYY):
Sex (Check one):Male Female Other
Race (Check one):White/Caucasian *Hispanic Black/African American American Indian or Alaska Native Asian Hawaiian Native or other Pacific Islander Multi-racial Other
**Disability:Yes No
***Veteran:Yes No
Highest Grade Completed:High School Graduate
Graduation Date:
GED:GED
Date GED Attained:
Some Post H.S., no degree or certificate Certificate (< 2 years) Associate Degree Bachelor Degree or Above
Applicant Signature:
Clear
Date Signed:
Washington law requires the following information to be supplied to each student enrolling in a private vocational school licensed under RCW 28C.10. One copy of this notice bearing original signatures must be attached by the school as an addendum to that individual’s enrollment agreement and a copy must be provided to the enrollee by the school.
DEBT ACKNOWLEDGMENT BY ENROLLEE
I understand and accept that any contract for training I enter into with the above named school contains legally binding obligations and responsibilities.
I understand and accept that repayment obligations will be placed upon me by any loans or other financing arrangements I enter into as a means to pay for my training.
I understand that any enrollment contract I enter into will not be binding or take effect for at least five days, excluding Sundays and holidays, following the last date such a contract is signed by the school and myself, provided that I have not entered classes sooner.
Name (Please print):
Signed:
Clear
Dated:
ACKNOWLEDGMENT BY SCHOOL
Prior to being enrolled in this school, the applicant whose name and signature appears above has been made aware of the legal obligations he/she takes on by entering into a contract for training. Those discussions included cautions by the school about acquiring an excessive debt burden that might become difficult to repay given employment opportunities and average starting salaries in his/her chosen occupation.
Title:
Keri Sork, Executive Student Administrator
