New Registered Dental Assisting (RDA) Application

Monroe 2-Orleans BOCES CWD

3589 Big Ridge Road, Spencerport, NY 14559

Registered Dental Assisting (RDA) Application

General Student Information

Program

Are you a current or former student at BOCES 2?

Yes No Not Selected

First Name

Middle Name

Last Name

Name Suffix

Gender

Preferred Pronouns

Birth Date

Social Security No

Cell Phone

Home Phone

Street

Mailing Street2

City

State/Province

Zip/Postcode

Mailing Address (if different from physical address)

Street Address

Street Address 2

City

State

Zip Code

High School Information

High school diploma or equivalency is required for enrollment. Please upload a PDF or JPEG of your valid diploma.

Click here to read our handbook and learn more about diploma requirements.

High School Diploma Status

HS Diploma/HSE Transcripts Upload

Employment Information

This information is used to understand your needs and goals. Please note, entry into this program requires at least 30 days of employment as a dental assistant and dentist sponsorship. Please upload a signed Sponsoring Dentist form. PDFs and JPEGS accepted.

Click here to download the Sponsoring Dentist Agreement. Complete it and upload it below before submitting your application.

Employment Status at Entry

Employer at Entry

Hourly Wage at Entry

Sponsoring Dentist Form Upload

Emergency Contacts

Please include the name of someone to contact in the event of an emergency of if we are not able to contact you using your contact information.

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Cell Phone

How did you hear about us?

Referral Organization

Referral Individual

Signature and Release of Information

Click here to review the student handbook, which includes the code of conduct and other important policies and information: https://www.monroe2boces.org/StudentHandbook.aspx

Form Completed By: (Please Print)

Full Name Signature

Date Signed

Equal Opportunity Notice

BOCES does not discriminate on the basis of age, sex, race, religion, color, national origin, disability, creed, marital status, veteran status, military status, sexual orientation, prior criminal offense, domestic violence victim status, gender identity, gender expression, or genetic status in its programs or activities and provides equal access to the Scouts of America and other designated youth groups. The following person has been designated to handle complaints/inquiries regarding the BOCES’ non-discrimination policies: Director of Human Resources, 3599 Big Ridge Road, Spencerport, New York 14559, 585-352-2420, and is also the Title VII and Title IX Officer. For further information on notice of non-discrimination, visit http://wdcrobcolp01.ed.gov/CFAPPS/OCR/contactus.cfm for the address and phone number of the office that serves your area, or call 1-800-421-3481. Please note that those wishing to file a complaint may also do so through the Department of Education’s Office for Civil Rights at https://www2.ed.gov/about/offices/list/ocr/complaintprocess.html. See also New York State Executive Law 296.

I certify that the information provided on this application is complete and accurate. I realize that failure to provide correct information is sufficient cause for reconsideration of my admission status. Release of information: By participating in this state and/or federally funded adult education and/or family literacy program, I agree to the release of the information contained in my program records, including, but not limited to, social security number, assessment results and attendance, to the New York state Department of Education (NYSED). Required information for learner participation is indicated with an asterisk (*). This information may include follow-up with employment data and other educational records and will be used in aggregated or non-personally identifiable form, for reporting as required by state and federal laws. This information may also be used for research and analysis purposes during this year and/or subsequent years. Information provided will remain secure. Unless otherwise noted, only NYSED, its authorized contractors or the local program will have exclusive access to this information.