Fall 2025 Registered Dental Assisting Application

Applicant Information

Have you applied before?(Required)

Your Name(Required)

First Name Middle Name Last Name

Palomar Student ID Number(Required)

Date of Birth(Required)

Best Contact Phone Number(Required)

Home Address(Required)

Street Address Address Line 2 City State ZIP Code Country

Palomar Student Email Address(Required)

Enter Email Confirm Email

Personal Email Address(Required)

Enter Email Confirm Email

Demographic Data Questions

This demographic data information is reported to state and federal agencies for statistical purposes only. The way options are written are directly from the reporting agency and do not represent how Palomar College views our students. If you prefer not to answer any question(s), please choose the “Other” option for that question.

Gender

Choose “Other” if you do not identify as either male or female.

Citizenship

If you have citizenship in a country other than the US or Canada, please choose “Other”.

Race/Ethnicity(Required)

This question applies to US citizens, resident aliens, and other eligible non-citizens only. Non-resident aliens should choose the “Nonresident alien” option. Individuals originating from the Middle East and North Africa should choose “White”. Individuals originating from India and Pakistan should choose “Asian”.

Is English your 1st language?

Language(s) Spoken at Home(Required)

List all.

Emergency Contact Information

Emergency Contact Name(Required)

First Name Last Name

Relation to Applicant

Ex. Mother, Father, Sibling, Husband/Wife/Domestic Partner, etc.

Best Contact Phone Number(Required)

Best Contact Email Address(Required)

Enter Email Confirm Email

Applicant Educational Experience

Highest level of education completed by the start of the term(Required)

Your High School

Only list the school you received your high school diploma from.

High School Name Location of School Graduation Year

Proof of High School Graduation/College Degree(Required)

Upload a PDF copy of your : (1) high school transcripts showing date of graduation, (2) passing score on the General Education Development test (GED), (3) high school diploma or graduation certificate (if you graduated high school outside of the US), or (4) transcript or diploma of college degree earned

Drop files here or

Accepted file types: pdf, Max. file size: 49 MB.

List of Colleges & Universities Attended(Required)

Make sure to list Palomar College as a school attended. For the Institution GPA, make sure to state the GPA for that specific school, not a cumulative GPA that may include transferred credit.

Name of College/University

Location of School (City, State)

Term System (Quarter/Semester)

Start Date (MM/YYYY)

End Date (MM/YYYY)

Institution GPA

Unofficial Transcript Copies(Required)

Upload an unofficial transcript for each school listed in PDF format.

Drop files here or

Accepted file types: pdf, Max. file size: 49 MB.

Dental Prerequisites

DA 50: Intro to Dental Science and Dental Occupations

Term (ex. Spring 2025)

Grade Received

DA 57: Dental Sciences and Anatomy(Required)

Term (ex. Spring 2025)

Grade Received

ENG 100: English Composition (or equivalent)

ENG 100 is a corequisite and can be completed during the 1st term of the program. If you have already completed this course, please state so below.

Term (ex. Spring 2025)

Grade Received

Electronic Signature Agreement(Required)

By typing my name, I agree and understand that I am electronically signing this application and that this is the legal equivalent of my manual/handwritten signature.