WIXLIB

4. Transcripts and Grades: In addition to the electronic transcripts submitted to admissions,please enclose official transcripts in your dental hygiene application packet. Include all collegesyou have attended, including Blinn College. Each transcript should be submitted in a sealedenvelope and will generally be marked with a school seal and/or signature on the back of theenvelope. Dual Credit students should submit the transcript of the college they attended, nottheir high school transcript, to receive credit for classes completed.Only those courses achieved with a “C” or better are considered when determining the pointsvalue for admission. Anatomy & Physiology II must have been completed within the past 5years (no earlier than fall 2016) and Microbiology must have been completed within the past 3years (no earlier than fall 2018).5. ATI TEAS: Complete the ATI TEAS. Scores from the ATI TEAS will not be sent directly to theprogram. Print your ATI TEAS score sheet(s) and enclose them in your application packet. Weneed the score sheet that reports the scores for all 4 subject areas and not just the overallscore. Your score sheet must have your name and the date of the test on it. Test scores do notexpire, and older results are acceptable in this application. We use the highest score in eachcategory, so you may include multiple score sheets. Additional information on ATI TEAS testingis found on the “ATI TEAS for Health Sciences” document in this application.6. Recommendation forms: Submit three (3) completed recommendation forms from employers,members of the clergy, teachers, civic leaders, or individuals unrelated to you that would befamiliar with your qualifications for the dental hygiene profession. You must use 3 uniquesources (i.e., 1 employer/co-worker, 1 teacher, 1 long-time family acquaintance, etc.). Personalfriends are not acceptable. Letters/forms must be received in individual sealed envelopes andsubmitted with your complete packet. Please attach an envelope to the form for therecommender and use the provided form.7. Observations: Observation of a registered dental hygienist is not required for this applicationcycle due to COVID-19.8. Community Service: Additional points may be earned through community service hours.Community service is not required but is highly encouraged to boost the points total in yourapplication. Community service comes from the heart and where you volunteer is entirely yourchoice and should be with an entity that is near and dear to you. Points will be awardedincrementally for up to 40 hours. You may use the enclosed form for documentation, or youmay provide a signed letter, on letterhead, from a supervisor. Community service must occurbetween the following dates: Feb. 1, 2021 – Jan. 31, 2022.2 of 3BCDH Application Procedures Guide

9. Verification of Employment: Please provide letters from employers for verification ofemployment. Points will be awarded for work experience totaling up to two years, either parttime or full-time, in any field.10. Professional Certifications: Applicants can earn one point for holding a current professionalcertification or license in a field that requires such certification for employment opportunities.Examples include Certificate of Cosmetology, Electrician, Certified Teacher, etc. Basicregistrations such as Registered Dental Assistant are not accepted. Please include a copy ofyour certificate with your ID number visible. Certificates may be verified.11. Interviews are NOT a part of the application process. All points will be calculated based on thepoints rubric provided in the application.12. Additional Documentation: Please do NOT submit unnecessary documentation such asresumes, photos, immunization records, CPR cards, proof of extracurricular activities, or highschool transcripts.13. Submission of Application: Please submit your application packet, which includes theapplication form, official transcripts, recommendation forms, ATI TEAS, proof of employment,copies of certifications, and community service activities in a 9 X 12 envelope.The packet must be postmarked or delivered to the Dental Hygiene office no later thanTuesday, Feb. 1, 2022, 5:00 pm.Failure to meet this deadline will disqualify your application for the fall 2022 class.Each applicant is responsible for ensuring that the Blinn College Dental Hygiene Program hasreceived all information. Any application that is incomplete will not be considered for thefall 2022 start date.14. Verification of Delivery: It is highly recommended that you keep proof of mailing and/orrequest a return receipt if mailing via US mail, UPS or FedEx. Blinn College Dental Hygiene willalso send an email to the address provided verifying that your packet has been received within3- 5 business days.3 of 3BCDH Application Procedures Guide

Blinn CollegeDental Hygiene ProgramApplication Completion FormFall 2022(Please complete and attach to the front of your application packet after you review,validate and sign)Name Blinn ID# DOB (Month/Day ONLY)Please place a check mark ( ) by all those items included in this packet, sign and date this form prior to mailing1.Program Application (completed and signed)2.College Transcripts (enclosed) Transcripts must be official and in sealed envelopesName of Institutiona.b.c.d.3.ATI TEAS- (scores enclosed)4.Recommendation Forms (enclosed) Recommendation forms must be in sealed envelopes.Name of Recommendera.b.c.5.Community Service Log6.Employment /Military service verification7.Professional CertificationStudent SignatureDate

FALL 2022BLINN COLLEGE DENTAL HYGIENE PROGRAMAPPLICATIONSECTION A – GENERAL INFORMATION1.Date:2.DOB: (month/day only)3.Full Name:4.Other names under which credentials may be received:5.Permanent Address:6.Mailing Address:7.Telephone Number: (h)8.E-mail Address you use:9.Emergency Contact: (name/number)10.Are you a citizen or permanent resident of the United States? Yes11.List all educational institutions (colleges, universities, and professional schools) in order of attendance.Do not omit the name of any institution where you have been a student. If necessary, use a separatesheet of paper.CreditDate AwardedSchool NameHoursDegree/ Certificateor Expected(Last)Blinn College I.D.#(First)(Number and Street)(MI)(City)(Number and Street)(City)cell(State)(State)(Zip)(Zip)No12. Are you eligible to return to each of these institutions? Yes NoIf no, please explain:13. Have you previously attended any health related programs? Yes NoIf yes, complete the following information:School Name:Address:Dates of Attendance: Graduated: Yes No Date:Type of Program:(Continue on next page)

SECTION B- EMPLOYMENT/COMMUNITY SERVICE/INFORMATION14. Begin with the most recent years of employment, and/or military service. Include letters and/orsigned statements from employers or DD-214, verifying up to 2 years of employment tenure/military status.Employer/Military ExperiencePhoneDatesJob TitletototoTotal number of years/months of employment and/or military service15. Total hours spent in community service activities from Feb. 1, 2021-Jan. 31, 2022 .Enclose Community Service Log or letters providing dates of activities on letterhead from a supervisor.SECTION C – PROFESSIONALISM16. Complete and sign the top portion of the forms, “Recommendation for Dental Hygiene”. Three (3) completedrecommendation forms must be received in sealed envelopes and enclosed in your application packet.References may be validated by our office.17. Enclose a copy of any current Professional Certifications you may have.SECTION D – ATI TEAS SCORES18. Scores from the ATI TEAS will NOT be sent directly to the program. Print and enclose all relevant ATITEAS scores in your application packet. We need to receive the score sheet with all 4 subject areas and notjust the overall score. Score sheet must have your name and date of test on it.SECTION E – OBSERVATION LOG19. Observation is not required for the Jan. 2021- Feb. 2022 application cycle.

SECTION F - COURSES AND CONTINUING EDUCATION FORM20. Complete the following table for required courses within the dental hygiene curriculum:A&P 2 must have been completed within the past 5 years. (no earlier than Fall 2016)Microbiology must have been completed within the past 3 years. (no earlier than Fall 2018)Gen. Academiccourses required fordental hygienedegreeCHEM 1405 orCHEM 1411 orCHEM 1305 &1105Intro. To ChemistryBIOL 2401A&PIBIOL 2402A & P IIBIOL 2420 or 2421MicrobiologyENG 1301Comp. & RhetoricSPCH 1311 or 1315or 1321SOCI 2326 or PSYC2319Grade (A-F)ORStatusIP InProgressNT NotTakenR-Repeated*DateCompleted*(N/A if notcompleted)College/UniversityLocation where completedCourseEquivalent(if not exact courselisted)Social PsychologyPHIL 2306Intro to Ethics*If you repeated a course, please place a * next to the grade. Use the date of the last course taken for the DATECOMPLETED column.SECTION G - MISCELLANEOUS21. A criminal background check and drug screening will be required for all applicants who are offered aposition. Further information will be provided if you are accepted into the program.If you have been convicted of a misdemeanor or felony, it is suggested that you complete a Criminal HistoryEvaluation (CHE) from the Texas State Board of Dental Examiners to ensure licensure eligibility upongraduation from the program. Graduation from the program does not ensure eligibility to be licensed and practicedental hygiene in the state of Texas. ory-evaluation/If interested in licensure in other states, please reference the individual states’ dental boards for information.

NOTEPossible Board Exam/Employment Qualifiers: Conviction of a felony or misdemeanor that relates to the duties and responsibilities of the licensedoccupation.Dependence on alcohol/drugs and other chemicalsDismissal from employment due to unprofessional or dishonorable conductRestriction, suspension, revocation or probation of licensure in another jurisdiction within the past10 yearsFailure to report disciplinary action received in another jurisdiction.For further information, contact evaluation/22. Signature:I certify that the information provided in this application is correct and complete. I understand that omission orfalsification of information is grounds for exclusion or dismissal. If accepted into the program, I agree to meet allentrance requirements and to confirm and abide by the letter and the spirit of the rules, regulations andprocedures of Blinn College and this program. In addition, I am aware that I will be subject to a criminalbackground check and drug testing (cost to the applicant) prior to beginning the dental hygiene program, ifaccepted. I have received a copy and read the Application Procedures Guide and the Communicable Diseasepolicy statement.SignatureDateIs your application complete? Please use the enclosed checklist to ensure your application is complete.Submit in a 9x12 envelope.Have you contacted the Dental Hygiene Program for answers to your questions concerning this application?We are very happy to help you!Submit the Dental Hygiene Application and all correspondence to:Blinn CollegeATTN: Dental Hygiene ProgramP.O. Box 6030Bryan, TX 77805-6030Or deliver to:301 Post Office St.Bryan TX 77801You are responsible for ensuring that all information has been received by the Blinn College DentalHygiene Program. Any application that is not complete cannot be considered for entrance into theprogram.

Blinn CollegeDental Hygiene Program Recommendation FormThis reference form is to be submitted with the application in a sealed envelope.References should be from teachers, employers, clergy, counselors, or commanding officers with whom the applicant has hadprofessional relationships. References from family members or friends are NOT accepted. Submitting inappropriate references willresult in fewer points than the maximum allows for this portion of the application process.Name of ApplicantTo assure that your records are held in compliance with the law as stated below*, please check one:I GIVE UP my right to access of this form.I DO NOT GIVE UP my right to access of this form.Applicant SignatureDateThe above named applicant is a candidate for admission to the Blinn College Dental HygieneProgram and has named you as a reference. Your comments will be used only by the admissionscommittee of the dental hygiene program to assist them in arriving at a better understanding of thisapplicant. Your cooperation in completing this form will assist both the applicant and the DentalHygiene Program.*Please Note: FERPA grants a student/applicant access to his/her records as maintained by the department of Dental Hygiene at BlinnCollege. It also grants a student/ applicant the right to waive access. See above for the student’s/applicant’s choice regarding confidentialityI have known the applicant in the following capacity:I have known the applicant for months years.I would evaluate the applicant as follows:Attitudes toward others (caring, respect)Ability to work with othersAbility to communicate orallyAbility to communicate in writingIndependenceInitiativeAbility to accept responsibilityPresentation of self (poise, courtesy, language)Potential for growthEXCELLENTABOVE AVERAGEAVERAGEBELOW AVERAGENOT KNOWNRECOMMENDATION:Strongly RecommendRecommendRecommend with ReservationNot RecommendComment (s):Signature Date PositionAddressTelephonePlease return this form to the applicant in a sealed envelope.

Blinn CollegeDental Hygiene Program Recommendation FormThis reference form is to be submitted with the application in a sealed envelope.References should be from teachers, employers, clergy, counselors, or commanding officers with whom the applicant has hadprofessional relationships. References from family members or friends are NOT accepted. Submitting inappropriate references willresult in fewer points than the maximum allows for this portion of the application process.Name of ApplicantTo assure that your records are held in compliance with the law as stated below*, please check one:I GIVE UP my right to access of this form.I DO NOT GIVE UP my right to access of this form.Applicant SignatureDateThe above named applicant is a candidate for admission to the Blinn College Dental HygieneProgram and has named you as a reference. Your comments will be used only by the admissionscommittee of the dental hygiene program to assist them in arriving at a better understanding of thisapplicant. Your cooperation in completing this form will assist both the applicant and the DentalHygiene Program.*Please Note: FERPA grants a student/applicant access to his/her records as maintained by the department of Dental Hygiene at BlinnCollege. It also grants a student/ applicant the right to waive access. See above for the student’s/applicant’s choice regarding confidentialityI have known the applicant in the following capacity:I have known the applicant for months years.I would evaluate the applicant as follows:Attitudes toward others (caring, respect)Ability to work with othersAbility to communicate orallyAbility to communicate in writingIndependenceInitiativeAbility to accept responsibilityPresentation of self (poise, courtesy, language)Potential for growthEXCELLENTABOVE AVERAGEAVERAGEBELOW AVERAGENOT KNOWNRECOMMENDATION:Strongly RecommendRecommendRecommend with ReservationNot RecommendComment (s):Signature Date PositionAddressTelephonePlease return this form to the applicant in a sealed envelope.

Blinn CollegeDental Hygiene Program Recommendation FormThis reference form is to be submitted with the application in a sealed envelope.References should be from teachers, employers, clergy, counselors, or commanding officers with whom the applicant has hadprofessional relationships. References from family members or friends are NOT accepted. Submitting inappropriate references willresult in fewer points than the maximum allows for this portion of the application process.Name of ApplicantTo assure that your records are held in compliance with the law as stated below*, please check one:I GIVE UP my right to access of this form.I DO NOT GIVE UP my right to access of this form.Applicant SignatureDateThe above named applicant is a candidate for admission to the Blinn College Dental HygieneProgram and has named you as a reference. Your comments will be used only by the admissionscommittee of the dental hygiene program to assist them in arriving at a better understanding of thisapplicant. Your cooperation in completing this form will assist both the applicant and the DentalHygiene Program.*Please Note: FERPA grants a student/applicant access to his/her records as maintained by the department of Dental Hygiene at BlinnCollege. It also grants a student/ applicant the right to waive access. See above for the student’s/applicant’s choice regarding confidentialityI have known the applicant in the following capacity:I have known the applicant for months years.I would evaluate the applicant as follows:Attitudes toward others (caring, respect)Ability to work with othersAbility to communicate orallyAbility to communicate in writingIndependenceInitiativeAbility to accept responsibilityPresentation of self (poise, courtesy, language)Potential for growthEXCELLENTABOVE AVERAGEAVERAGEBELOW AVERAGENOT KNOWNRECOMMENDATION:Strongly RecommendRecommendRecommend with ReservationNot RecommendComment (s):Signature Date PositionAddressTelephonePlease return this form to the applicant in a sealed envelope.

Blinn CollegeDental Hygiene ProgramCommunity Service LogStudent’s Name: Month/Day of Birth:* Community Service must occur between the following dates: Feb. 1, 2021 – Jan. 31, 2022Date of Event/Place Total hours of participationName of EventAddressPhone# Name of SupervisorSupervisor’s Signature DateDate of Event/Place Total hours of participationName of EventAddressPhone# Name of SupervisorSupervisor’s Signature DateDate of Event/Place Total hours of participationName of EventAddressPhone# Name of SupervisorSupervisor’s Signature DateDate of Event/Place Total hours of participationName of EventAddressPhone# Name of SupervisorSupervisor’s Signature

The Dental Hygiene Program is a two-year program that begins in the fall semester each year in Bryan, TX. Enrollment is limited to 14 each year. Blinn College offers the Associate of Applied Science (A.A.S.) degree in Dental Hygiene. Upon successful completion of the program, the student is awarded the A.A.S. in Dental Hygiene and is