DENTAL ASSISTING ENROLLMENT AGREEMENT
Please verify all boxes are filled in order to proceed.
All CAPITAL letters!
This agreement is entered into on this *day of *, 2023,
between APLMED ACADEMY (“Academy”) and *(“Student”).
Full Legal Name:
City: *State: * Zip:
E-mail Address: *
Confirm E-mail Address: *
Cell Phone: *
Program Title: DENTAL ASSISTING – CERTIFICATE PROGRAM
Start Date *
Cost of program is payable by check, credit card or money order made payable to APLMED ACADEMY. Please be sure the applicant’s full name is written on the check. Checks retuned due to insufficient funds will be assessed a $25.00 fee. Student account must have a zero balance at the end of class term to be able to continue on to clinicals.
Registration Fee (Non-refundable) $150.00
Supplies/Equipment (Non-refundable) $100.00
Total Cost of Program $2800.00
Schedule of Payments
Deposit of $500.00 is due at the time of registration. You may also elect to pay in full or come in to the facility to schedule payment arraignments of the remaining cost minus deposit. Late fee of $50.00 will apply to each late payment.
Student’s Signature of Acknowledgement * Date *
The Academy assists in placing students to an externship site within three (3) months after the classroom training if students volunteer and meet all requirements for the externship. Externships are limited in availability and student must meet certain criteria to be considered. The school will inform the student of the date and time of the externship in a timely matter and the student must be available. Students have the option of completing the program without the externship to receive a certificate of completion. Students who do participate in the externship must successfully complete the externship to receive a certificate of completion *
Students’ conduct requirements for externship:
Patient and student safety is of utmost importance. Therefore, if the instructor believes that actions demonstrated by the student could jeopardize either the student’s or patient’s safety, the student will not be allowed to start/continue the externship.The student must meet the following criteria to be considered for an externship:
1. Demonstrate sufficient emotional stability to withstand the stresses, uncertainties, and changing circumstances that characterize patient/clients and their families *
2. Exercise sound judgment, accept direction and guidance from a supervisor or faculty member and establish and maintain sensitive interpersonal relationships with employees, patients/clients and their families *
3. Demonstrate excellent communication skills (reading, writing, and listening comprehension) in the English language *
4. Ability to work under stress and respond appropriately in emergencies or unexpected situations *
5. Demonstrate fine motor skills required to successfully perform blood draws, process specimens (operating mechanical and computerized equipment) and perform clerical duties *
Postponement of Start Date
Postponement of start date, whether at the request of the Academy or the Student, requires a written agreement signed by the Student and the Academy. The agreement must set forth:
a.) whether the postponement is for the convenience of the Academy or Student, and
b.) a deadline for the new start date, beyond which the start date will not be postponed.
If the course is not initiated, or the Student fails to attend by the new start date set forth in the agreement, the Student will be entitled to an appropriate refund of prepaid tuition and fees within 30 days of the deadline of the new start date set forth in the agreement, in accordance with the Academy’s refund policy and all applicable laws and rules concerning the Private Occupational Education Act of 1981.
Complaints, which cannot be resolved by direct negotiation between the Student and the Academy, may be filed online with the Division of Private Occupational Schools of the Colorado Department of Higher Education, either online at www.highered.colorado.gov/dpos, or by calling (303) 862-3001. All Student complaints submitted to the Division must be in writing and “shall be filed within two years after the Student discontinues training at the Academy.”
1. Students not accepted to the Academy are entitled to all monies paid. Deposits $500.00 is NOT Refundable.
2. The Student may withdraw at any time ** Deposit is Non Refundable
3. After the commencement of classes any payments made towards tuitions is not refundable.
4. The Student will receive a full refund of all tuition & fees paid if the Academy discontinues a program/stand-alone course within a period of time that the Student could have reasonably completed it, except that this provision shall not apply in the event the Academy ceases operation *
5. The student will receive a full refund of any monies paid if the class is postponed and the student cannot attend the new schedule *
6. Detailed information on refunds and the refund policy is available in the financial office. Please contact us for more details.
2600 S Parker Rd Bldg 6 Ste 300
Hours of operation:
Monday -Friday 9:00 a.m. - 5:00 p.m
1. Administration has the right to not accept students into externships who have missed classes. Every student who misses a class must make up the lost hours for a fee of $50.00 *
2. A student who misses a class with a valid reason must bring supporting documentation and make up the class for a fee of $50.00 *
3. APLMED Academy has the right to expel a student with two missed classes without a refund *
4. Students must behave respectively and professionally to the teacher, school staff and staff of the externship *
5. Student must wear scrubs to all classes *
6. All the books are a property of AplMed Academy which is complementary rented to students. Books have to return by the end of the course. Writing in the books is not permitted. For any damages there will be an additional fee from $20.00 to $50.00 depending on damage *
By signing below, the Student agrees to pay APLMED ACADEMY the total stated tuition, fees for books, supplies, and equipment. The Academy agrees to provide the occupational training in accordance with the provisions of the Academy’s current Catalog Volume No. 6 , dated January 1, '.date("Y").' Payment of all monies due shall be a condition of continuing enrollment. Upon satisfactory completion of all academic and skill requirements, and when all financial obligations to the Academy have been met, the Academy will award the CERTIFICATE OF COMPLETION to the Student. The Student and Academy understand that this Enrollment Agreement, WHICH INCLUDES THE REFUND POLICY, may not be amended except in writing and signed by both parties.
At the time of enrollment, students must provide the following:
1. High school diploma, GED or a copy of college transcripts
2. Government -issued State ID (driver’s license, passport, military ID, matricula consular)
3. Social Security Card
4. Immunizations Records
• PPD (tuberculosis test)
• Influenza (During flu season only)
I, * have received a copy of this APLMED ACADEMY ENROLLMENT AGREEMENT and a copy of the current APLMED ACADEMY CATALOG.
Applicant’s Signature * Date *
APLMED ACADEMY is Approved and Regulated by the
Colorado Department of Higher Education, Private Occupational School Board
I agree to pay 500.00 not refundable deposit. *