Legal first name *

Legal last name *

Phone *

Email *

By checking this box, I agree to receive text messages from the National Institute of Dental Assisting about my application and enrollment. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help.

By checking this box, I agree to receive marketing and promotional text messages from the National Institute of Dental Assisting at the phone number provided. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help.

Date of birth *

Home address

Street Address *

State *

City *

ZIP code *

Highest level of education completed *

Middle name

Name you go by, if different

Emergency contact name *

Emergency contact's relationship to you *

Emergency contact phone *

Which program are you applying for? *

Which class would you like to join? *

How did you hear about NIDA?

Name of your high school or GED program *

School city and state *

Year you graduated or completed *

Have you worked in a dental or medical office before? *

Yes, in a dental office

Yes, in a medical office

What made you decide on dental assisting?

The hands-on training meets in person on weekends in Wilmington. Can you attend? *

Yes

I need to talk through my schedule first

Do you have computer access and reliable internet? *

Yes

Not sure

Tuition is $3,500 and your $500 deposit goes toward it. How do you plan to pay the balance? *

Pay in full

Payment plan

I'd like financing information

Not sure yet

Upload a photo of your government-issued photo ID *

JPEG, JPG, PNG or PDFDriver's license, state ID or U.S. passport. A clear phone photo of the front is fine.

Which type of ID is this? *

Is your high school transcript, diploma, or GED ready to upload? *

Yes, I'll upload it now

No, I'll send it later

You can apply today and send it later. We need it on file before your first day of class.

Which document are you sending? *

Upload your transcript, diploma, or GED

JPEG, JPG, PNG or PDF ( max 3 Files )Skip this if you are sending it later.

Please read and check each box *

Everything I entered on this application is true and complete.

I understand my $500 deposit holds my seat, is applied to my tuition, and is subject to NIDA's refund policy.

I understand that finishing the program does not guarantee a job or a specific wage.

I agree that NIDA may keep my ID and education documents in my student file.

Signature *

Clear