REGISTRATION FORM – SEALANT COURSE
REGISTRATION FORM
Radiation Safety (X-Ray Licensure) Certification Course
California Rural Indian Health Board Inc.
The following course is being provided by Foundation for Allied Dental Education (FADE), an agency accredited by the Dental Board of California.
The Dental Support Center will pay the registration fee of $475/per student
Please print clearly the information below and complete all spaces where applicable.
Name (please print):________________________________________
Email: __________________________________________________
Dental Office Facility: ______________________________________
Address: _________________________________________________
City: ____________________________________________________
State: ________ Zip: __________
Home or cell phone: ( ):______________
Work Telephone ( ):_________________
Office Fax # ( ):____________________
Class Dates: September 29 – October 1, 2017
Location: Foundation for Allied Dental Education (FADE)
4995 Golden Foothill Parkway
El Dorado Hills, CA 95762
Class Hours:
September 29, 2017 (1:00 p.m. – 6:00 p.m.)
September 30, 2017 (8:30 a.m. – 4:30 p.m.)
October 1, 2017 (8:30 am. – 4:30 p.m.)
Please note: All participants must have a current CPR certification issued by the American Heart Association or Red Cross. Thank you.
Please submit your registration form and required CPR card by September 15, 2017 to
Eva-Marie Del Puerto. Thank you.
Eva-Marie Del Puerto, Dental Support Center Coordinator
Email: edelpuerto@
Phone: 916-286-7236 ext. 1321
Fax: 916-929-7246
Radiation Safety Course for CRIHB as follows:
• Eight (8) hours of home study provided two weeks prior to classroom attendance (provided to enrollee directly by mail and email)
• Day One - Friday on-campus: 1:00 p.m. to 6:00 pm for didactic review, demonstration and safety testing
• Day Two - Saturday on-campus: 8:30 am – 4:30 pm for lab skills
• Day Three - Sunday on-campus: 8:30 am – 4:30 pm for completion of lab and one clinical competency (patient will be student partner)
• Completion of final clinical competencies in the workplace under the direct supervision of a licensed dental healthcare provider using clinical evaluation criteria provided by the program.
Total: Eight (8) hours home-study, 20 hours on-campus, and four (4) hours workplace
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- nevada business registration form online
- medical marijuana registration form pa
- vanguard account registration form pdf
- new patient registration form template
- patient registration form microsoft word
- patient registration form word document
- medical patient registration form template
- patient registration form word document free
- patient registration form template
- business registration form jamaica
- nj dmv registration form pdf
- combined employers registration form oregon