Georgia Dental Association Course Enrollment

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URL

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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.

Course(Required)

Please choose a course from below.

Confirm Course Selection(Required)

I confirm the course above is my intended course.

Course Total

GDA (ADA) License Number(Required)

Registrant's Name(Required)

First

Last

Registrant's Address(Required)

Street Address

Address Line 2

City

State

ZIP Code

Doctor's Name(Required)

Registrant's Email(Required)

Enter Email

Confirm Email

Registrant's Cell Phone(Required)

Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Registrant's Date of Birth(Required)

Registrant's Social Security Number(Required)

Course Total

Coupon Code

Credit Card

Card Details

Cardholder Name