Indiana University School of Dentistry

INDIANA UNIVERSITY SCHOOL OF DENTISTRY

(IUSD)

DENTAL HYGIENE PROGRAM-IUPUI CAMPUS

Application open date: October 11, 2016

APPLICATION DUE: February 1, 2017

I am applying to the Dental Hygiene Bachelor Degree Program:

PersonalInformation

*Legal name (as it appears on your passport or government issued ID)

First Name ______Middle Name ______Last Name______Suffix: ____

*Will your documents arrive under another name, such as a former name?

Yes No

Please list any other names under which documents may arrive.

First Name ______Middle Name ______Last Name______Suffix: ____

*Do you have a name you would prefer we use when we call you, meet on campus, or send you an email?

Yes No Preferred Name: ______

IUPUI Student I.D.(required)______

If you have not applied to IUPUI, online application is located here:

Birthdate____/____/____ Gender: Male Female

*What is your country of birth? ______

*What is your state of birth? ______

*What is your city of birth? ______

*What is your country of citizenship? ______

*What is your native language? ______

Ethnic Information

Are you Hispanic or Latino? Yes No

What is your race? (Select all that apply)

• American Indian or Alaska Native

/

• Asian

/

• Black or African American

• Native Hawaiian or Other Pacific Islander

/

• White

Current Mailing Address:

*Country: ______

Line 1
Line 2
City / State
Postal Code / County

*Is your current mailing address also your permanent address? Yes No

If not, enter permanent mailing address below:

Permanent Mailing Address

______City ______State____

Zip Code______Country______

Current Phone

(___) ___-____

Email Address (required for official school communication)

______@______

Background Checks:

All accepted students will be required to have a background check. Background checks and any associated paperwork must be completed and turned in the week prior to the beginning of dental hygiene program.

Education:

List all schools

Post-Secondary Schools attended (COLLEGE, UNIVERSITY, COMMUNITY School EDUCATION). List ALL

Name of School/College and Location / Years Completed / Diploma or GED degree? / Major
High School/Location
College/Location
College/Location
College/Location
College/Location

Note: if necessary, you may attach a sheet with additional schools and employment history

Have you completed a Dental Assisting Certificate Program (C.D.A.)? Yes No

E.F.D.A Certification: Yes No If yes, Year Received: ______

Dental Assisting Program Name: ______Year attended: ______

Please describe any Dental Assisting Experience (include duties):

Types and Amount of DA Experience: Chairside Number of Years______

E.F.D.A. Number of Years______

Front Desk Number of Years ______

Laboratory Number of Years ______

A currenttranscriptfrom EACHcollege, or universityattendedmustbereceivedbytheIndianaUniversitySchoolofDentistrywiththis applicationdue date, FEBRUARY 1, oftheyear youwishtoenter the dental hygiene program. In addition, you must send your official final spring semester transcript to IUSD by the requested date.

NOTE:This isin addition to thetranscripts senttoIUPUI.

Employment: Please list employment starting with present or most recent employer.

Employer: ______PositionTitle: ______

HoursPer Week: ______LengthofEmployment: ______

BriefJobDescription:

Employer: ______PositionTitle: ______

HoursPer Week: ______LengthofEmployment: ______

BriefJobDescription:

Note: if necessary, you may attach a sheet with employment history

Volunteer/Community Enrichment History:Please list any groups or communities in which you have participated.Also include the year of participation and your designated role with these groups.

Group: ______Year: ______

Role: ______

Group: ______Year: ______

Role: ______

Other Information:

1.Have you previously applied to one of the IUSD Dental Hygiene Programs? Yes No

Please list Year/years that you applied: ______

Result of that application: Offered Alternate position ____Alternate number Not Accepted

Application not completed

2. Is English your first language? Yes NoIf No, you may be required to take T.O.E.F.L. Test

Listlanguages youspeakfluentlyotherthanEnglish:______

3. Have you ever been arrested or convicted of a crime that has not been expunged by a court? Yes No

4. Do you have any currently pending criminal charges against you? Yes No

5. Have you ever been disciplined for student conduct violations (e.g. academic probation, dismissal, suspension,

disqualification, etc.) by any college or school? Yes No

6. Have you ever been refused admission to a school or university or subject to any disciplinary action (e.g.

academic probation or dismissal) Yes No

7. Have you engaged in any behavior that resulted in serious injury to any person(s) or personal property?

Yes No

If you answered yes to any of these questions, please explain in detail. Note that answering yes to any of these questions will not automatically disqualify you from admission, but failure to disclose could result in denial of admission or subsequent disciplinary action, including dismissal.

APPLICANT’SPERSONAL STATEMENT:

TheDental Hygiene Admissions Committeerequires thatyouwriteandsubmitapersonal statementusingthecriteria listed below:

•500wordsor less

•Describewhatyou havebeen doingwhile in college(describeextracurricular activities in which you were involved)

•Explainreasonyouchose dental hygiene as the profession in which you want to be a part.Describeanyspecial qualities youpossess thatwill helpyouin this profession.

•Describeany leadership andorvolunteer roles you haveheldorcurrentlyhold.

•Describeanyobstaclesthatyoumayhavehadtoovercometomeet your goals.

~~~~~PLEASEATTACHYOURPERSONAL STATEMENTTOTHISAPPLICATIONAS A PDF DOCUMENT~~~~

Howdidyoulearn about ourDentalHygiene program?

Family or Friend IUPUI website IUSD website Dental Hygiene website Teacher/School

Other (please list)______

CODE OF CONDUCT: After reading the code of conduct and by checking the box at the bottom of the page,

you are indicating that the information provided is accurate and complete, failure to do so may jeopardize your application.

I agree to act with honesty, forthrightness, and integrity throughout the admissions process. I will be professional throughout the application process including interactions with IUSD, DH staff, program/school admissions officers and staff or admissions committees.

I agree to the following IUSD – Dental Hygiene (DH) Release Statement and Code of Conduct.

• I have read, reviewed, and understand the application instructions and program/school-specific admissions requirements, including provisions which note that I am responsible for monitoring and ensuring the progress and status of my application and all supporting materials.

• I have provided IUSD-DH information in this application that is complete and accurate to the best of my knowledge. I understand that omitting relevant information or providing misrepresentations or false or misleading information in my application and supporting documents during the application process may jeopardize my application or other actions, including the possibility of expulsion from a program, if enrolled.

• I certify that all written passages, such as the personal statement, essays, and descriptions of work/activities, are my own and have not been written, in part or in whole, by a third party.

•I understand that all documents provided to IUSD-DH will not be returned to me.

• I understand that an official transcript is required by IUSD-DH for all college level institutions I have previously attended, and that failure to provide these required documents may cause my application to remain incomplete. By submitting my IUSD-DH application, I am indicating that I have requested official copies of my college level transcripts be sent directly to IUSD-DH.

•I acknowledge my responsibility to inform the programs/school to which I have applied in the event there is any change in the information I have provided, including, but not limited to, educational information, legal and conduct violations, and contact information and in a timely manner. Programs/school will consider new information submitted, and in appropriate circumstances, reserve the right to change the status of an applicant or student.

•I authorize IUSD-DH to which I am applying to investigate any information, including my educational background, disciplinary history, and record of criminal convictions that it believes is relevant to my application.

•I give permission to release the information provided within my application, as well as all supporting application materials to IUSD – DENTAL HYGIENE.

•I agree to receive communication and respond to this communication by dates listed from IUSD-DH.

•I authorize the use of information provided within the application for research, applicant tracking, and reporting purposes.

Iherebygive permissiontotheDentalHygieneAdmissionsCommitteetoinspect myapplication and academic records.Iverifythattheinformation providedistruthfulandcorrect.

______ Printedfull Name Signature Date

IherebygranttheDentalHygieneAdmissionsCommittee permissionto download documentsfromIUPUI’ssecure databasesandsavethem intoasecure folderto bereviewed aspart ofthe admissionsprocess.

______ Printed full Name Signature Date

Application deadline is FEBRUARY 1, 2017. Please scan and send this application plus allrequiredmaterials(personal statement, observationhours plus verification from dentist office on official letterhead) and e-mail to . Officialtranscripts must be sent directly from your previous schoolby mail to:

Indiana UniversitySchoolof Dentistry

Dental Hygiene Program Admissions

1121WestMichigan Street, RoomS409

Indianapolis, Indiana 46202

or sent directly from your previous school electronically to .

APPLICATIONWILLNOTBEPROCESSEDUNLESSCOMPLETED ANDDATED

If you have questions, contact us at:

Indiana UniversitySchoolof Dentistry

Dental Hygiene Program Admissions

1121WestMichigan Street, RoomS409

Indianapolis, Indiana 46202

Phone:317-274-7801

Fax:317-274-1363

10/11/2016

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