Utah College of Dental Hygiene SIS and LMS Portal.Powered By Classe365

Personal Information

First Name^*

Middle Name

Last Name^*

Maiden Name

No Maiden Name

Check if N/A

Applicant Email^*

Applicant Phone #^*

Secondary Applicant Phone #

Profile Picture

NOTE: By providing your email and phone number above, you give UCDH representatives permission to contact you via email, phone call, or text.

Date of Birth^*

Example MM-DD-YYYY

Gender^*

Race^*

Marital Status^*

Social Security Number (SSN)^*

What is your state of Legal Residence?^*

Which US State are you a legal resident of?

U.S. Citizen^*

Yes No

If you do not have a Social Security Number, please contact the UCDH Admissions Department before submitting your application.
UCDH is currently not accepting applications from foreign nationals, i.e. DACA, F-1, F-2, J1, J2, G series visa's, and other categories not included under U.S. citizenship.

Physical Address

Physical Address^*

City^*

State^*

Zip Code^*

Country^*

Permanent Mailing Address

Permanent Mailing Address^*

In the event you change addresses during the application stage or while in the program, list an address you can reliably receive mail to, regardless of your living address. (This may be the same as your Physical Address if no other addresses available).

City^*

State^*

Zip Code^*

Country^*

Address belongs to:^*

Myself Immediate family Relative Friend Other

Check all that apply

Emergency Contacts

Provide the names and contact information for two individuals, preferably including a parent, who always know how to contact you. Please notify UCDH of any subsequent changes in any of your contact information. If you want to authorize UCDH to discuss your application with someone other than yourself, please contact the admissions office for a release of information form.

Contact 1 - Name^*

Contact 1 - Relation^*

Contact 1 - Mailing Address^*

Contact 1 - Phone #^*

Contact 2 - Name^*

Contact 2 - Relation^*

Contact 2 - Mailing Address^*

Contact 2 - Primary Phone^*

Application Essay

Why would you be a successful dental hygiene student and professional?^*

Academic Details

ACT/SAT Score

ACT/SAT Score Upload

Please attach an unofficial photo or scan of your ACT/SAT Score. This may also be listed on your High School Transcript or can be accessed through the ACT/SAT websites. Note: we do not have a school code with the ACT/SAT. If you access your score through those websites, request it for "personal use", then screenshot the score and upload it below. We do not require official copies.

Colleges/Universities Attended^*

Please list all Colleges/Universities attended. If possible include date ranges for each institution.

Prior Degrees

List prior degrees (do not include certificates or training courses)
Include the College/University and type of degree.

Degree 1 Award Date

Degree 2 Award Date

Applicant Prerequisite Audit

APPLICANT PREREQUISITE AUDIT: To aid admissions representatives in knowing what to look for regarding your academic history, students must fill out the Prerequisite Audit Section. This will outline when and where you took each of your prerequisite courses, along with the grade and credit hours awarded. This will be useful in identifying and verifying this information on your Official Transcripts.

NOTE: Prerequisites do not need to be completed at the time of application. However, all prerequisites must be completed by the time the program begins.

When completing the Prerequisite Audit Section below, please follow the format as shown in the example below for ALL the prerequisites. If you have not taken a prerequisite, please list the semester it is expected to be completed, along with the same information that is requested below.

SAMPLE FORMAT: B+ 3.0 CHEM 1010 Introduction to Chemistry - Brigham Young University
(Grade or semester to be completed, credit hours, course number, course title, college/university)

Anatomy^*

Anatomy Lab^*

Physiology^*

Physiology Lab^*

Microbiology^*

Microbiology Lab^*

Chemistry^*

Nutrition^*

Psychology^*

Sociology^*

English^*

Public Speaking^*

Math^*

PREREQUISITE RETAKES: Applicants are responsible for reviewing the UCDH prerequisite retake policy on our website (https://bit.ly/3FNyM9w) prior to applying. Applicants that are ineligible due to this policy and still submit an application, will not be issued a refund of their application fee.

I have read and understand the Prerequisite Retake Policy^*

I understand

TRANSFERABILITY: If your course is not listed in our course equivalencies and you believe the course to be transferrable, download and print the Petition for Course Transfer Review. Any potential transfer course must meet UCDH criteria and course content must match the majorify of the required foundational knowledge. Petitions are only valid for the current application cycle. If an applicant submits a petition for one application cycle and then applies to a different application cycle at another date, a new petition would need to be submitted. Any past petitions would be void. If you are uncertain whether a petition form is needed for any courses you have taken, or if you have any questions, please contact the admissions department via email. To submit petitions, email the completed form, course description, and syllabus to admissions@ucdh.edu.

Petition for Course Transfer Form: https://bit.ly/3Lc41w2

Transcript Submission

TRANSCRIPT SUBMISSION: In order to evaluate eligibility for admission, students must submit Official Transcripts. To be considered official, the transcript must be a sealed, hard copy and mailed directly from the institution to UCDH. Official transcripts are required for high school and ALL college/university courses you have attended, even if prerequisites were not taken there.
Please contact all institutions you have taken secondary education courses from and have "Official" versions hard copy mailed to the following address:

Utah College of Dental Hygiene
Admissions/Records Office
1176 South 1480 West
Orem, UT 84058

Upon receipt of your transcripts, UCDH representatives will record relevant data and assess the fulfillment of the prerequisites.

Confirm^*

I understand

I understand my application will not be considered complete, and will not be reviewed until Official Hard Copy Mailed Transcripts have been sent to UCDH.

Dental Experience

Amount of Dental Experience

Programs Completed

ADA Accredited Dental Assisting ADA Accredited Dental Lab Tech Non-ADA Accredited Dental Assisting Non-ADA Accredited Dental Lab Tech

Please mark if you have completed the following programs:

Shadowing Form Download: https://bit.ly/3CI4Rz8

Shadowing Form Upload

Please attach the completed and signed UCDH 2023 Observation Shadowing Hours Log. If your hours are not completed at the time of this application, please list below when your 40 shadowing hours are planned to be completed.

Shadowing Expected Completion Date

Please list the date your 40 shadowing hours are planned to be completed.

Lead Source

How did you hear about UCDH?

Attestation

RE-APPLICANTS: If a re-applicant has previously been offered a conditional acceptance by UCDH in the past, and declined or withdrew, they will only be considered for alternate positions in the class they apply for. This also applies to any applicants that have started the program and willfully withdrew early.

Are you a Re-applicant?^*

Yes No

Confirm^*

I understand

BLOODBORNE PATHOGENTS STATEMENT: Students in the Dental Hygiene program may be exposed to bloodborne pathogens and other infectious and/or life threatening diseases while providing clinical services at UCDH. Students are provided with instruction on mechanisms of disease transmission and other potential risks associated with infectious diseases, including infection control procedures that can be used to potentially reduce the risk of disease transmission. The instruction on infectious diseases includes those published by national public health agencies, the Occupational Safety and Health Administration (OSHA) and the U.S. Centers for Disease Control and Prevention (CDC).

After acceptance into the BSDH program, students will be provided with a list of required immunizations, which must be completed prior to beginning the program.

Confirm^*

I understand

ETHICAL ATTESTATION: I hereby certify that, to the best of my knowledge, the information in this application is true and complete without intent of evasion, false documentation, or misrepresentation.
I understand that if any information, at any time, is submitted to the UCDH Records Office under false pretenses or is not entirely accurate, truthful, is falsified in any way, or misrepresents in any fashion, that this will be sufficient cause and grounds to have my application rejected or revoked. This may also include a revoking of any awarded status by the admissions office and may also include immediate dismissal from the program.

Confirm^*

I understand

Fees

Mandatory Fees
	Application Fee	50
	Total	50.00

UCDH Program Application - January 2024 Start

Personal Information

Physical Address

Permanent Mailing Address

Emergency Contacts

Application Essay

Academic Details

Applicant Prerequisite Audit

Transcript Submission

Dental Experience

Lead Source

Attestation

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