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Foundations of Dental Assisting Application

Through funding provided by the American Rescue Plan Act, Coronavirus State and Local Fiscal Recovery Fund, Lee County residents may be eligible for scholarships covering the cost of tuition and books for the Foundations of Dental Assisting program. Complete the Lee County Registration section of this application to apply.

Please note:

  • Scholarships are dependent upon proof of residency within Lee County.
  • Recipients of the award must agree to provide Hodges with employment status updates (approximately 6 months and 12 months following completion of the program).

Personal Information

All cohort meetings will take place on our Fort Myers campus for six consecutive Saturdays from 9 AM to 1 PM
Legal Name*
Date of Birth*

Permanent Address*
Is permanent address the SAME as mailing address?*
Mailing Address*

Citizenship

Are you a U.S. citizen or Permanent Resident?*
Is English your primary language?*

Ethnicity & Gender

Legal Gender*
Are you Hispanic or Latino?*
Select one or more of the following races:*

Educational Information

Have you completed high school?*
Can you provide graduation dates/information for high school completion?*
Are you currently a student at Hodges University?*
Are you a Hodges University alum?*
Have you completed a college degree (Associate, Bachelor's, Masters or Terminal) or completed any college credits?*
What college degree(s) have you completed? (Select all that apply.)*
How many college credits have you completed?*
Are you currently CPR certified?*
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File uploads may not work on some mobile devices.
Expiration Date of CPR License*
If accepted, do you have transportation for getting to and from clinical/internship locations?*
I understand I will need to (1) complete a criminal background check and (2) obtain immunization records.*

Emergency Contact Information

Emergency Contact Name*
Emergency Contact Relationship*
May Hodges contact the emergency contact if necessary?*

Lee County Registration

Are you a resident of Lee County Florida?*
What is your current employment status?*
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File uploads may not work on some mobile devices.

Consent Agreement

To the extent the General Data Protection Regulation (“GDPR”) is applicable to me, I hereby consent to the processing of my Personal Data as defined by the GDPR for the purposes outlined and provided for in Hodges’ policies, as amended from time to time.  I understand that in certain circumstances, I have the right to object to the processing of my Personal Data.  I further understand that I have the right to request (1) access to my Personal Data; (2) rectification of mistakes or errors and/or erasure of my Personal Data; (3) that Hodges restrict processing of my Personal Data; and (4) that Hodges provide my Personal Data upon request in a portable format.

Yes, you may contact me. I understand that by submitting this form, I may be contacted by Hodges University or its representatives by phone, SMS, email or postal mail. Data rates may apply.