2017-18 Dental Assistant Application for Jordan District Students

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This application is designated for students who attend schools within the Jordan School District (Bingham, Copper Hills, Herriman, Riverton, Valley, West Jordan). Students who attend schools outside of the Jordan School District must not use this application.

First Name *

Last Name *

Jordan School District Student Number *

Grade (During 2017-18 School Year) *

Gender *

Birthdate *

YYYY

Home High School *

Bingham

Copper Hills

Herriman

Riverton

Valley

West Jordan

Home Phone

Home Address *

City *

Zip Code *

Father's First & Last Name (or Guardian)

Father's Work # (or Guardian)

Father's Cell # (or Guardian)

Mother's First & Last Name (or Guardian)

Mother's Work # (or Guardian)

Mother's Cell # (or Guardian)

Student's Cell #

Student Lives With *

Student E-Mail

Parent E-Mail

Which session do you prefer (AM or PM)? *

Why are you interested in Dental Assisting? *

If interested, please list the name of a 2nd choice program if you are not admitted to Dental Assisting.

Acknowledgement *

I authorize JATC personal to review my high school transcript, attendance record and Skyward assessment records as consideration for my application. I also acknowledge that I must provide my own transportation to and from clinical site.

Required

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