Dental Application | Allegany College of Maryland

Application Form for the Dental Hygiene Program

Class Entering Fall 2025

Last Name:

First Name:

Maiden Name:

Middle Initial:

Telephone Number: (Only One is Required)

Cell Phone:

Home Phone:

Work Phone:

Mailing Address:

Street:

City:

State:

Zip Code:

Email:

Verify Email:

Are you transferring from another college:

If transferring, please complete the following information:

Name of Institution:

Institution Address:

Dates of Attendance:

Degree or Credit or hours completed:

Add Additional Institution

Remove Additional Institution

Name of Institution:

Institution Address:

Dates of Attendance:

Degree or Credit or hours completed:

Please select any of the classes or their equivalent listed below that you will be taking or retaking during the Fall 2024 or Spring 2025 semesters for consideration for the Dental Hygiene Program:

English

Chemistry

Human Anatomy & Physiology

Microbiology

Psychology

Sociology

Speech

Math (Statistics)

Have you ever previously been enrolled in the clinical phase of a Dental Hygiene program at ACM or any other institution?

If yes, where?:

Have you completed all of the Allegany College of Maryland Admissions requirements including application for admission:

High School Transcripts (You must also file a regular college application)

College Transcripts

Are you currently enrolled in classes at ACM:

If yes, student ID number:

I certify that all the statements given on this application are true and accurate to the best of my knowledge.

I also certify that it is my responsibility to notify the Dental Hygiene Department of any changes in address, phone number(s) and email addresses that may occur after the submission of this application.

I further acknowledge that the Dental Hygiene Department will communicate with me using the information provided on this application. The Dental Hygiene Department will not be responsible for my failure to receive important communications and respond to them in a timely manner, as a result of the department having inaccurate contact information.

Applicant's Signature: