HDAS Enrollment Application
Personal Information
First Name
*
Last Name
*
Email
*
Mobile Phone Number
*
Date of Birth
*
Gender
*
Select
Male
Female
Prefer not to answer
Do you have a social security number?
*
Select
Yes
No
Street Address
*
City
*
State
*
Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
*
Did you graduate from High School or obtain a GED?
*
Select
Yes
No
Graduation Date
*
Name of Institution/School
*
Full Legal Name
*
Which session are you applying for?
*
Select Which session are you applying for?
Spring 2024 (3/23/24-6/8/24)
Summer 2024 (6/22/24-9/14/24)
Fall 2024 (9/28/24-12/7/24)
Winter 2025 (1/11/25-3/15/25)
Which school location are you applying for?
*
Select Which school location are you applying for?
Clear Lake - TX
Katy - TX
The Woodlands - TX
Clear Lake - TX
Katy - TX
The Woodlands - TX
Clear Lake - TX
Katy - TX
The Woodlands - TX
Clear Lake - TX
Katy - TX
The Woodlands - TX
*Must select your preferred session selection prior to selecting location.
Which payment option works for you?
*
Select
Full Payment - $3850
Option A - $1675 Deposit (10 Weekly Payments of $238)
Option B - $975 Deposit (10 Weekly Payments of $318)
*A minimum deposit of $975.00 is required to reserve a seat. The deposit is deducted from the cost of tuition and is 100% refundable if you choose to cancel your enrollment.
How did you find us?
*
Select
Friend/Family Member
Former HDAS Student
Internet/Search Engine
Social Media
Newspaper
School Function
Dentist Practice Referral
Other
Referred by name
*
How did you hear about HDAS/why did you choose our program?
*
Why do you want to become a Dental Assistant?
*
Are you currently employed? If yes, briefly describe what you do:
*
Are you currently in school? If yes, what are you studying?
*
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