Dental Hygiene Application

Dental Hygiene Program Application

Big Spring
Howard College is committed to providing safe and non-discriminatory learning, living, and work environments for all members of the College community. In accordance with applicable federal and state law, the College prohibits discrimination, including harassment, on the basis of race, color, national or ethnic origin, religion, sex, pregnancy, disability, age, sexual orientation, veteran status, or any other legally protected characteristic in employment, educational programs, and admissions.
PERSONAL INFORMATION
First Name*
Last Name*
Middle Name
Maiden or Previous Name
Birth Date*

MonthDayYear
Birthplace
City, State
Social Security*
Contact Phone*
Please enter a phone number where you can be reached or receive messages.
Email*
example@example.com
Mailing Address

Current address where you can receive mail
City*
State*
ZIP*
Permanent Address (if different from mailing address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

College Classification*

Classification Freshman (0-29 hours)Classification Sophomore (30-59 hours)Classification Unclassified (60 + hours)
Tell us why you want to be a Dental Hygienist!*

STATISTICAL INFORMATION
Please select,

MaleFemale
Ethnicity

White, Non-HispanicAmerican IndianBlack, Non-HispanicHispanicAsian, Pacific IslanderOther, Foreign Student

PREVIOUS EDUCATION
Are you a High School Graduate (or have you completed your GED Equivalence)?*

YesNo
Date of Graduation
Name of High School
Location - City, State
Have you attended (or are you currently enrolled at) another college?*

YesNo
If "Yes" please list other colleges attended.
Have you ever attended another Dental Hygiene program?*

YesNo
If "Yes" please list the name of the program
Example: Austin Community College - Dental Hygiene Program
If you have attended other colleges or programs, please upload/attach a copy of your unofficial transcript.

Kindly attach all necessary documents. These may include, but are not limited to: Medical Exam Form, Dental Exam Form, Observation Hours documentation, etc.
Attach files here

Cancelof

Acceptance Acknowledgement
If I am accepted as a student at Howard College, I will honor all administrative summons and conform to and abide by the letter and spirit of all the rules, regulations, and procedures of Howard College as given in the college catalog and student handbook. I hereby give the right to disclose to appropriate college officials my school records for use in planning my program. I certify the above information is complete and correct. I acknowledge that deliberate omissions or falsifications may subject me to immediate dismissal from the college.
I have reviewed and understand the Texas State Board of Dental Examiners (TSBDE) Criminal History Evaluation (make it a link using https://tsbde.texas.gov/licensing/criminal-history-evaluation/

I understand I will be required to submit a criminal background check and drug screen before acceptance into the program.

If I am not accepted into the program I will need to re-submit my application.
DATE*

MonthDayYear
Signature*

Clear
Should be Empty:

Mailing Address