GDA Course Enrollment

Step 1 of 2

Program Selection(Required)

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 peddentasstschool@gmail.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

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)

Social Security Number(Required)

Course Total

Credit Card

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