Bachelor of Science in Dental Hygiene (Bsdh)

DENTAL HYGIENE APPLICATION BACHELOR OF SCIENCE IN DENTAL HYGIENE (BSDH) 1COMPLETE AND RETURN TO: University of Hawai'i at Mānoa Today’s Date: School of Nursing & Dental Hygiene ______Please print clearly or type. Department of Dental Hygiene 2445 Campus Road, Hemenway 200-B APPLYING FOR: Honolulu, Hawaii 96822 Fall: 20______DEMOGRAPHICS FORM FOR BACHELOR OF SCIENCE (BSDH)

NAME: ______Birth Date: _____/_____/______SEX:

Student Banner No. : ______-______Birth Place: ______F _____ M

ADDRESS PHONE, etc, (Current): Street Number & Name: ______Curr: (____)______

City: ______State: ______Zip Code: ______Perm: (____)______

(Permanent): Street Number & Name: ______Work: (____)______Cell or City: ______State: ______Zip Code: ______Pager :______e-mail: ______

NAME OF HIGH SCHOOL: ______YEAR GRADUATED: ______LOCATION: ______

SAT: Verbal: ______Math: ______High School Quintile: ______

Military Status: (Mark “X” on all that applies on Branch and Status. If dependent of, mark “D” on Branch and Status):

Branch: ____ Air Force ____Navy Status: ____ Active Duty Served in: ____ OIF ____ Army ____Coast Guard ____ Veteran ____ OEF ____ Marines ____National Guard ____ Reservist

COLLEGES OR UNIVERSITIES ATTENDED: * Degree Transcript Name of College/University From-To(Mo/Yr) _CRS. GPA_ Major Received Date Requested/In

1.______

2.______

3.______

RESIDENCY: Hawaii: ___Yes ___No If no, of what state or country are you a legal resident? ______How many years? ______Visa: ___ F-1, ___ J-1, Other: ______

ETHNICITY: (Check all that apply)

__Native Hawaiian/Part-Hawaiian/Mixed Hawaiian __Caucasian or White __Korean __Samoan __African American or Black __Laotian __Tongan __Asian Indian __Thai __Guamanian or Chamorro __Chinese __Vietnamese __Micronesian __Filipino __Other Asian __Other Pacific Islander __Japanese Are you Hispanic or Latino? ____Yes ____No Are you of Native Hawaiian ancestry? __Yes __No

Have you applied to UHM Dept. Dental Hygiene before? ____ Yes ____ No IF YES, when? ______Sem. ______Yr.

Have you had an appointment with the Dental Hygiene Faculty Advisor? ____ Yes ____ No

Enter grade for pre-dental hygiene course requirements completed: Grade Course Grade Course Courses Enrolled in Currently: _____ Physiology 103 or equiv. (5) _____ English 100 (3) _____ Physiology 103L or equiv. (1) _____ Psychology 100 (3) _____ Biochemistry 241 or equiv. (3) _____ Sociology 100 (3) _____ Microbiology 130 (3) _____ Speech 151 (3) _____ Microbiology 140 (2) _____ Food Sci. & Human Nutri. 185 (3) "Disability Access: Students with disabilities and related access needs are encouraged to contact the UHM KOKUA Program for information and services. Services are confidential, and students are not charged for them. Contact KOKUA at (808) 956-7511 (V/T) or e-mail [email protected]. KOKUA is located on the ground floor, in Room 013, of the Student Services Center." *Kindly have official transcripts sent to the Department of Dental Hygiene. Updated: 05/7/2016