This form is not an application to the College. It is part of your application to the program.
Have you ever been a student at Lake Land College?*
If so, give dates attended
Please list employment starting with present or most recent employer.
How did you hear about the Dental Hygiene Program at Lake Land College?
If a person recommended the Dental Hygiene Program, please list that person’s name and address.
How did you become interested in Dental Hygiene?
IT IS STRONGLY RECOMMENDED THAT ALL HEALTH CARE PROVIDERS RECEIVE THE HEPATITIS VACCINE.
Hepatitis vaccine is available from your family physician or local clinic. Health care
workers are at risk for contracting hepatitis during patient care. For this reason, we
urge all of our students accepted into the program to be immunized. The immunization
consists of 3 injections administered into the arm. This is very important because
vaccine injected into the hip is not as effective. The first injection is followed by the
second, 30 days later and the final one is given in 6 months to produce immunity to
Hepatitis B. A surface antigen titer should also be performed after about 6 months to
I understand the Hepatitis Vaccine is strongly recommended.*
I have read and understand the Dental Hygiene Intent.*
Expected Date of Program Entry Fall semester of:
Expected Date of Completion Spring semester of:
Reminder: The deadline is January 31 for the year you are applying.
Students matriculating in and graduating from a Lake Land College health career program must be able to meet the technical requirements of the academic program and must not pose a threat to the well-being of patients, other students, staff, or themselves.
As an incoming student for the Dental Hygiene program, you will need, at a minimum, the following types of skills and abilities and will need to maintain and demonstrate these abilities throughout the program:
I have read and understand the Dental Hygiene Essential Functions Standards.*
Please correct the following errors and try again: