GDA Course Enrollment Step 1 of 2 50% Program Selection(Required) EDDACoronal PolishRadiology Course Affidavit(Required) I have a signed course affidavit I do not have a signed course affidavit, but will provide one before the course date. Signed Affidavit(Required) Max. file size: 50 MB. Requirements Acknowledgement(Required) I understand that I must provide a signed affidavit prior to the course date. A copy can be emailed to email@example.com or faxed to 770-578-8957 Requirements Acknowledgement(Required) I understand and have read the requirements, rules, and prerequisites of my course. The Atlanta Pediatric Dental Assistant School reserves the right to cancel any class that does not meet minimum participation requirements. All registration fees may be transferred to another course date if notification is received at least 30 days prior to the scheduled course date. Cancellations or transfers after that time will not be permitted. There are NO REFUNDS. GDA Membership(Required) GDA Member Dentist Non GDA Member Dentist GDA (ADA) License Number(Required) EDDA GDA Member Price: EDDA Non-GDA Member Price: Coronal Polish GDA Member Price: Coronal Polish Non-GDA Member Price: Radiology Price: Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Doctor's Name(Required) Email(Required) Enter Email Confirm Email Emergency Contact Name(Required) Emergency Contact Phone(Required) Date of Birth(Required) Month123456789101112 Day12345678910111213141516171819202122232425262728293031 Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Social Security Number(Required) Course Total Credit Card Email This field is for validation purposes and should be left unchanged.