Dental Careers Academy
1300 Marsh Landing Parkway, Suite 112
Jacksonville Beach FL 32250
904-699-9979
www.dentalcareersacademy.com
Student Enrollment and Financial Agreement
The total program cost for the ENTRY LEVEL DENTAL ASSISTING course of study offered by this institution
is:
$4,000.00
The above total program cost covers all costs for the course and includes the following:
Registration fee of $150.00, Books & Materials fee of $400.00, Tuition fee of $3,450.00
Lunch is not provided, however several eating establishments are within short walking distance.
The course will run ten (10) consecutive weeks, eight (8) classroom hours per week for a total of eighty (80)
classroom hours of instruction. This will include lecture material as well as clinical "hands on" training, for a
total of 80 course work hours.
The tuition fee includes all of the following:
• All training and visual aids, materials and all supplies used in the clinical training.
• Use of all equipment and instrumentation with actual "hands on" training during the course
of study. There no hidden costs or expenses once you get started.
• A Certificate of Completion in Entry Level Dental Assisting, Dental Assistant pin, and a letter of
recommendation outlining your training and experience will be awarded to all students who have
attained a 70% or above grade average.
• X-ray training in accordance with state regulations.
• Training in all phases of General Dentistry, including: Endodontics, Crown & Bridge, Cosmetic Bonding,
Amalgam Restorations, Impression Taking, Oral Surgery, Periodontics, 4-handed dentistry, front desk,
and much more!
• All training is done by dental professionals in a practicing dental office, not a classroom.
The program fees may be paid using one of the following payment options:
1. $4,000.00 at the time of registration.
2. $2,000.00 down payment, then $200.00 at the beginning of each class (10 payments).
3. CareCredit Extended Financing (see instructions and options on next page)
Continue enrollment and see terms and conditions on the following three pages.
Page 1 of 4
CareCredit Financing Application Instructions
You can apply for CareCredit financing in total
privacy using one of the two methods below:
1. By Phone: Call 1-800-365-8295 and follow
the automated prompts.
2. Online: Apply at www.carecredit.com Click
“Apply Now” Under "Eric S Burgess DMD
PA" put our phone #
904-699-9979
To insure approval, enter the total program fee
for the course when asked ($4,000.00), and
make sure all information is correct, especially
social security numbers. Include ALL sources
of house-hold income (salary, bonuses,
alimony, investments). Consider using a coapplicant if your application is denied.
Upon approval, you will be given a 16-digit
number beginning with “6”. Write this number in
the “CareCredit #” space above, complete the
rest of the information requested and send in to
our address above or FAX it to 904-273-9883.
Refunds and Cancellations
A graduation certificate, letter of recommendation, and pin will only be awarded to those
students attaining a 70% or above grade average.
All monies will be refunded if Dental Careers Academy does not accept the applicant or if
the student cancels within three (3) business days after signing the enrolment agreement
and making initial payment.
A full refund, minus the registration fee of $150.00, will be made of all deposits or
payments if cancellation is made before the start of the first class.
If cancellation or withdrawal is made after the first class, but prior to the second
class,100% of the tuition fee ($3,450.00) will be refunded, but the cost of registration fee
and books and material fee ($550) will not be refunded.
For cancellations between eight (8) to forty (40) clock hours, students that have paid the
tuition for the entire program ($3,450), will be charged a pro-rated amount of $43.125 per
clock hour that has been attempted, plus registration fee and books and material fee
($550) and any remaining balance will be refunded. The pro-rated amount of $43.125 per
clock hour is based on the tuition amount of $3,450 divided by eighty (80) clock hours.
There will be no refunds after the completion of 40 clock hours.
Refunds due will be made within 30 days of the date that Dental Careers Academy
determines that the student has withdrawn.
The withdrawal date of a student will be determined by either written notification by the
student or reports by the faculty.
Program Re-entry and Re-take
Students whose grade average is below 70% will not receive a certificate, but will be
allowed to retake the entire course (if desired) at a reduced fee of $3,000.00.
Those that provide a written request to cancel for illness or personal reasons, may
resume their course of study in the next class series with no penalty and may repeat the
already completed sessions if desired.
If a student that did not provide a written request drops out of the program at any point
and decides to re-register for a future class, not in the next series, full program fee of
$4,000.00, minus the $400.00 books and materials fee, will be charged and no credit will
be given to payments made for the previous class. Dropout status will take effect upon
closing of the eight (8) clock hours of the students’ second missed class during the ten
(10) week program in which they are enrolled or at the time the student submits a written
statement that he or she is dropping out.
I wish to register for the upcoming class and have selected one of the following payment options:
$4,000.00 Payment in Full (ENCLOSED)
 $2,000.00 Down Payment (ENCLOSED), then $200 per week for10 weeks.
Care
Credit
Check
Money Order
CareCredit Plan (application instructions are listed at top of page). I would like the payment plan below from CareCredit (check
ONLY if using Care Credit)
 $666.67 per month for 6 months (last payment will be $666.65) (NO interest; based on $4,000.00 loan)
 $187.00 per month for 24 months (11.9% APR)
The finance boxes below will be completed by Dental Careers Academy based on which payment plan above is selected.
ANNUAL PERCENTAGE RATE
FINANCE CHARGE
Amount Financed
The dollar amount the credit
provided to you or on your
behalf.
$
$
Total of Payment
The amount you will have paid
after you have made all payments
as scheduled.
%
Total Sales Price
The total cost of
your purchase on
credit including
your down
payment of
$
$
YOUR PAYMENT SCHEDULE WILL BE:
Number of Payments
Amount of each payment
When payments are due
Beginning on ____/____/____ and on the same day each
$
(check one) _____ weekly or _____ bi-weekly thereafter
Continue enrollment and see terms and conditions on the following two pages
Page 2 of 4
Please complete payment information below:
Name on Card: ______________________________________
Card Billing Address:
City: _____________________________
State: __________________ Zip: __________________
Cardholder Signature: X
Mail or FAX Payment & Registration to:
Dental Careers Academy, LLC, Attn: Student Registration, 1300 Marsh Landing Pkwy., Suite 112, Jacksonville Beach, FL 32250
Fax: 904-273-9883
How did you find out about our course?
Internet ☐
Vo-Tech School ☐
Newspaper Ads ☐ Former Student ☐
☐ Other: ______________________________________________________
Student Name (Print): ________________________________________________________
Street Address: ______________________________________________________________
City: __________________________________________________ Zip: ________________
Phone: (______)__________________ Email: _____________________________________
Social Sec #: __________________________ D.O.B.: _____/_____/_________
M/F
Please select one of the following program enrollment periods:
I wish to enroll in the Entry Level Dental Assisting Program that starts on the following Saturday:
o
o
o
July 16th, 2016
October 1st, 2016
2017 (dates to be determined)
Classes will be held each Saturday from 8:00am - 4:00pm for 10 consecutive weeks from start to completion of
the program, unless a holiday weekend falls during the program, in which case, the next class would resume
the following Saturday.
The July 2016 program is estimated to start July 16th, 2016 and complete September 24th, 2016.
The October 2016 program is estimated to start October 1st, 2016 and complete December 17th, 2016.
The January 2017 program dates are to be determined.
Continue enrollment and see terms and conditions on the following three pages.
Page 3 of 4
GROUNDS FOR TERMINATION
I agree to comply with the rules and policies and understand that Dental Careers Academy shall have the right to
terminate this contract and my enrollment at any time for violation of rules and policies as outlined in the catalog. I
understand that Dental Careers Academy reserves the right to modify the rules and regulation, and that I will be advised
of any and all modifications.
GRADUATION REQUIREMENTS
I understand that in order to graduate from the Entry Level Dental Assisting program and to receive a diploma, I must
successfully complete the required number of scheduled clock hours as specified in the catalog and on the Student
Enrollment Agreement, pass all written and practical examination with a 70% average and satisfy all financial obligations
to Dental Careers Academy.
EMPLOYMENT ASSISTANCE
I understand that Dental Careers Academy has not made and will not make any guarantees of employment or salary upon
my graduation. Dental Careers Academy will provide me with placement assistance, which will consist of identifying
employment opportunities and advising me on appropriate means of attempting to realize these opportunities.
Procedures for Termination or Cancellation of this Enrollment Agreement
Once a student is enrolled in Dental Careers Academy, Entry Level Dental Assisting program, each student assumes the
obligation to conduct himself or herself in a manner compatible with Dental Careers Academy, LLC. In the event that a
student does not uphold conduct guidelines (as listed in the program catalog), it may result in the following actions;
Conduct Warning or Probation, Loss of Privileges, Transcript notation (approved by the President), Suspension or
Removal from program (approved by President), Suspension, Expulsion, Revocation of a degree or certificate, Referral to
the appropriate legal authorities.
I agree that I have read the conduct guidelines listed in the program catalog for Dental Careers Academy and that I fully
understand that if I violate the conduct guidelines, I may be subject to termination of this agreement at the schools’
discretion.
ACKNOWLEDGEMENT
This contract contains the entire agreement between Dental Careers Academy and myself, and no further modification or
representation except as herein expressed in writing will be recognized.
NOTICE TO PROSPECTIVE STUDENTS: DO NOT SIGN THIS CONTRACT BEFORE YOU HAVE READ IT OR IF IT CONTAINS ANY
BLANK SPACES. ALL SIGNERS HAVE RECEIVED AND READ A COPY OF THE BINDING DOCUMENT AND CATALOG.
X_____________________________________
Signature of Applicant
__________________
Date
X_____________________________________
Signature of School Official
__________________
Date
Page 4 of 4