Your big opportunity may be right where you are now. Napoleon Hill
Idea Transcript
6301 South Halsted Street Chicago, IL 60621 Voice: 773.602.5219 Fax: 773.602.5220 http://kennedyking.ccc.edu
Dental Hygiene Program DIVISION OF CAREER PROGRAMS
Dental Hygiene Application Applications for the Dental Hygiene Program are due January 31, 201 Submit supporting documents to: Kennedy-King College Dental Hygiene Program, Building Y, Room 161, 6301 S. Halsted Street, Chicago, IL 60621.
Students new to Kennedy-King College must also apply for admission to the College. Visit Room W240 to meet with a college advisor or call 773.602.5062.
Right Handed
Left Handed
Have official transcripts from all schools attended sent to KKC Dental Hygiene Program (address above).
Term applying for:
Summer of 201
Applicant Information _________________________
____________________ ______________
____ - ___ - ______
Last Name
First Name
SSN
_________________________
___________________
_______
________
__________
Permanent Address
City
State
Zip Code
County
Gender
Male
Ethnicity
Asian/Pacific Islander Hispanic
Middle Name
Date of Birth _____________________
Female
American Indian/Alaskan Native Other
Black, non-Hispanic White, non-Hispanic
_____________________ ___________________
________________
___________________
Home Phone
Business Phone
E-mail Address
Cell Phone
_________________________________________
________________
___________________
Emergency Contact Name
Relationship
Phone
Educational History List all colleges or universities attended since high school graduation, including any of the City Colleges of Chicago. Continue list on separate sheet of paper if necessary. If you have never attended college, write “N/A.” For office use only
College/University
State Dates of attendance
Degree Earned
Health Care Experience List all health care experiences, paid and volunteer work, beginning with your present position. You may use a continuation sheet if you need more space. Institution Name and Address
Duties ___________________________________________________________________________________________ _________________________________________________________________________________________________ Reason for Leaving _________________________________________________________________________________
Completed Course Prerequisite (must completed with grade C or higher prior to admission) Course
School
Credit Hours
Final Grade
General Biology I ________________________________________ Anatomy & Physiology I ________________________________________ Anatomy & Physiology II ________________________________________ Basic Chemistry I ________________________________________ *HQHUDO0LFURELRORJ\________________________________________ +XPDQ 'LYHUVLW\ ________________________________________