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

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