Canadian College of Dental Health
Dental Hygiene	Application Form

Date of Application:

Enrolment Date:

(  ) Spring     (  ) Fall

I. Personal Information

Name:
	SURNAME	FIRST NAME

Address:

City:

Postal Code:

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Telephone:

Date of Birth:

Gender:

M

F

E-mail address:

Languages:

Spoken:	English	French	Other:
Written:	English	French	Other:

                    II. Medical History

In order to be accepted by Canadian College of Dental Health, you must attach or have forwarded our

entry immunization form (provided by the College) indicating good health, freedom from all communicable

diseases and an up-to-date immunization and T.B test (if the T.B test is positive a yearly chest x-ray is

required as well as follow up treatment.)

III. Academic Education Training

Secondary School:

City:

Completed Grade:

From:

To:

Post Secondary              Institute:

Degree Diploma:

From:

To:

Post Secondary              Institute:

Degree Diploma:

From:

To:

Attach copies of diplomas, degrees, certificates and transcripts

________________________________________________________________________________________

Canadian College of Dental Health

Mail to: 760 Brant Street Burlington, ON. L7R 4B7 or Fax to: 905-632-2895

Telephone: 905-632-3200 or 1-877-278-8888

www.ccdh.ca

	Canadian College of Dental Health
Dental Hygiene	Application Form

                     V. Character References

Please indicated two original reference letters of your good character from non-family members, who have

known you for more than two years. Letters must be signed, dated and include the individuals address and

phone number.

Name:

Address:

Occupation:

Telephone:

Years Known:

Name:

Address:

Occupation:

Telephone:

Years Known:

                      VI. Please check the following:

                     (  ) Academic transcripts (diploma, degree, certification) forward directly to the College from the Institution

                     (  ) Current (written) criminal background check from the applicant’s local Police Department

                     (  ) Standard First Aid and Level C CPR

                     (  ) Entry Immunization Form

                     (  ) Two character references

                     (  ) Statement of motivation

                     (  ) Application fee $75

                     (  ) Testing fee $75

I agree to allow Canadian College of Dental Health collecting the personal information about me in this

document  in order to provide the services requested. I understand that the information is protected and treated

confidentially and that I have the right to review it.

Signature of applicant:

_______________________________________________________________________________________

Canadian College of Dental Health

Mail to: 760 Brant Street Burlington, ON. L7R 4B7 or Fax to: 905-632-2895

Telephone: 905-632-3200 or 1-877-278-8888

www.ccdh.ca