Buchanan County Technology & Career Center
Dental Assistant
1124 Almarine Drive
Route S Box 110
Grundy, Virginia 24614
Phone: (276)935-4541 FAX: (276)935-4682

Date:

PLEASE PRINT OR TYPE

Name Telephone Number

Last First Middle

Maiden Name Social Security Number

Address

Street and Number City State, Zip

Date of/Place of Birth

Date City State

In an emergency, contact Tel. No.

Address

Citizen of

Circle highest grade completed in school: 7 8 9 10 11 12 Year Graduated______or GED

Name, address and year(s) of high school attended:

Other education or training (including night school). List name, address, and years of attendance

SCHOOL / ADDRESS / YEARS ATTENDED

Have you ever applied to this school before? ______If so, when?______

If so, state name, address, and years of attendance ______

Have you ever been convicted of a felony or misdemeanor? Circle the answer: Yes or No.

If yes, please explain______

Revised April 1999

Revised June 2007

Revised Sept 2010

Revised February 2012

The Buchanan County School Division does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs and activities.

Revised April 1999

Revised June 2007

Revised Sept 2010

Revised February 2012

The Buchanan County School Division does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs and activities.

Buchanan County Technology Career Center

Registration Application

Student Age Date

Trade Phone

Address______

City State Zip

Date of Birth Place of Birth

Social Security Number

Name of Parent or Guardian

Occupation of Parent or Guardian

Business Phone Number Cellular Phone/Other

Number of miles from home to BCTCC

Is your health good? Fair Poor

List serious illnesses ______

Do you have a part-time job? □Yes □No

Where?

What type of work are you doing?

How many hours a week do you work?

Revised April 1999

Revised June 2007

Revised Sept 2010

Revised February 2012

The Buchanan County School Division does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs and activities.