Radiology Student Registration Form

Full name

Email

Phone number

Street address

City

State

ZIP code

Government-issued photo ID

Upload your file

Choose a file or drag and drop one here.

Please upload an image or document of your government-issued photo ID.

I confirm I have current or prior dental assistant experience through employment, training, or education.

I authorize ModernDent Training of Cumming to photograph or record me during classes, labs, clinical activities, school events, and graduation, and to use those images or recordings for the school's website, social media, educational materials, and promotional materials without compensation.

Photo release signature

Date signed

Radiology Student Registration Form