San Juan College
Dental Hygiene Program
Application 2016
Name of Applicant: ______________________________
For Department Use Only:
Date Received: ____________________
By: ___________________________________
Signature
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Welcome
The San Juan College Dental Hygiene Program is a selective program and admission is limited.
Students seeking to enter must complete the following application and all required steps prior to the
deadline of April 7, 2016. We look forward to receiving your application!
If you have any questions regarding the application process, please do not hesitate to contact us:
Dental Program
Phone: (505) 566-3642 / Fax (505) 566-3652
[email protected]
Please take a moment and tell us how you heard about the SJC Dental Hygiene Program.
 Internet Search
 Word of Mouth
 Dentist/Hygienist
 Brochure
 Advisor
 Other: ____________________________
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Guidelines
Please utilize the following guidelines to ensure that you have completed all of the required steps
necessary for applying to the San Juan College Dental Hygiene Program.


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If you have previously applied to the SJC Dental Hygiene Program and would like to reapply,
you are required to fill out a new SJC Dental Hygiene Program application.
Before you apply, please make sure you meet all of the minimum eligibility requirements
listed in the SJC Academic Catalog and also listed on our website at;
www.sanjuancollege.edu/hygiene.
If you have not done so already, you must contact the SJC Dental Hygiene Program to set up
an appointment with our Program Advisor to conduct a review of your eligibility.
Before you apply to the SJC Dental Hygiene Program, you must apply to and be accepted to
San Juan College.
o This is not the same as applying to and being accepted to the SJC Dental Hygiene
Program. By applying to San Juan College, we can properly determine which of the
prerequisite and general education courses you have taken will transfer. This is the
first step, and without it, we cannot determine the eligibility of courses you have taken.
o To apply to San Juan College, go to http://www.sanjuancollege.edu/pages/3590.asp.
(Online application is FREE. Paper application is $10.00). When you apply to San Juan
College, please be sure to mark Pre-Dental Hygiene as your major.)
Send all official transcripts to the San Juan College Office of Admissions. (Not directly to the
SJC Dental Hygiene Program).
o This process may take 3-4 weeks. Please be sure to have your transcripts sent in well
ahead of the application deadline!
o You may request to have your transcripts sent electronically. Please have them emailed
directly to the San Juan College Office of Admissions at
[email protected].
Complete all of your Prerequisite and General Education Courses.
o You may have courses “in progress” at the time you apply to the SJC Dental Hygiene
Program. All of the prerequisite courses must either be completed or in progress at the
time of the SJC Dental Hygiene Program application, and must be completed prior to
entering the SJC Dental Hygiene Program. Utilize the In Progress Grade Report Form to
have your Professors report your “in progress grades”. These should be sent directly to
the SJC Dental Hygiene Program.
Please have your ACT scores sent directly to San Juan College Office of Admissions and
include a copy of your ACT scores with your application by the application deadline.
 Deadline: Thursday, April 7, 2016 at 5:00pm.
Please submit all pages of your
completed application to: San Juan College
Dental Hygiene Program
4601 College Blvd.
Farmington, NM 87402
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Section A – Personal Information
LAST
M.I.
FIRST
1) Name of Applicant
2) San Juan College ID #
STREET NAME & NUMBER
APT. #
CITY
STATE
ZIP CODE
STREET NAME & NUMBER
APT. #
CITY
STATE
ZIP CODE
3) Physical Address
4) Mailing Address
5) E-Mail Address
6) Home Phone Number
(
)
7) Work Phone Number
(
)
8) Cell Phone Number
(
)
Are you a New Mexico Resident?
Yes
No
Are you a resident of any one of the following Colorado counties?
(Montezuma, Archuleta, Dolores or San Juan)
Yes
No
Students meeting the residency and/or special residency status as defined in the San Juan College Academic Catalog will
be given a 5% Residency Preference on their application.
Have you ever been convicted of a felony?
Yes
No
Individuals who have been convicted of a felony may have limited employment opportunities in the dental field.
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Section B – Educational Institutions
Please list all Educational Institutions, High School and above, and Health Related Programs you
have attended in the order you attended them.
1) Name of Institution:__________________________________________________________________
Address: ___________________________________________________________________________
Phone Number: ______________________________
Health Related Program: Yes No
Degree(s) and/or Certificate(s) Accomplished: ___________________________________________
____________________________________________________________________________________
2) Name of Institution:__________________________________________________________________
Address: ___________________________________________________________________________
Phone Number: ______________________________
Health Related Program: Yes No
Degree(s) and/or Certificate(s) Accomplished: ___________________________________________
____________________________________________________________________________________
3) Name of Institution:__________________________________________________________________
Address: ___________________________________________________________________________
Phone Number: ______________________________
Health Related Program: Yes No
Degree(s) and/or Certificate(s) Accomplished: ___________________________________________
____________________________________________________________________________________
4) Name of Institution:__________________________________________________________________
Address: ___________________________________________________________________________
Phone Number: ______________________________
Health Related Program: Yes No
Degree(s) and/or Certificate(s) Accomplished: ___________________________________________
____________________________________________________________________________________
Have you ever been dismissed from a professional program or academically withdrawn from a
profession program?
Yes
No
If yes, complete the following information:
School Name and Location: _________________________________________________________________
Dates of Attendance: _______________ to _______________
Type of Program: _________________________________________________________________________
Are you in good standing and eligible to return to the program?
Yes
No
If no, please explain: _______________________________________________________________________
__________________________________________________________________________________________
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Section C – Educational Courses
Please fill out the Prerequisite Courses you have completed in the chart below.
Send all official transcripts to San Juan College Office of Admissions. (Not directly to the SJC Dental Hygiene
Program). This process may take 3-4 weeks. Please be sure to have your transcripts sent in well ahead of the
application deadline! You may request to have your transcripts sent electronically. Please have them emailed
directly to the San Juan College Office of Admissions at [email protected].
PREREQUISITE
COURSES
Course ID
(eg BIOL 121)
Course Title
Final
Grade
Date
Completed
Course
Status
C = Completed
I = In Progress
NT = Not Taken
Institution
Where Course
Was Taken
Introductory Biology I
BIOL 121*
Human Anatomy &
Physiology I
BIOL 252*
Human Anatomy &
Physiology II
BIOL 253*
Microbiology
BIOL 224*
Introductory Chemistry
OR Higher
CHEM 110*
Math for Health Careers
OR Higher
MATH 114
Freshman Composition
ENGL 111
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Section C – Educational Courses Continued
Please fill out the General Education Courses you have completed in the chart below.
Send all official transcripts to San Juan College Office of Admissions. (Not directly to the SJC Dental Hygiene
Program). This process may take 3-4 weeks. Please be sure to have your transcripts sent in well ahead of the
application deadline! You may request to have your transcripts sent electronically. Please have them emailed
directly to the San Juan College Office of Admissions at [email protected].
GENERAL
EDUCATION
COURSES
Course ID
(eg BIOL 121)
Course Title
Final
Grade
Date
Completed
Course
Status
C = Completed
I = In Progress
NT = Not Taken
Institution
Where Course
Was Taken
Introduction to
Sociology
SOCIO 110
Introduction to
Psychology
PSYC 120
Public Speaking
SPCH 110
OR
Interpersonal Comm.
SPCH 111
Advanced Composition
ENGL 211
OR
Adv. Tech. Composition
ENGL 218
Introduction to Nutrition
HLTH 118
In Progress Courses:
If you currently have courses “in progress” at the time of application, please have your Professor
complete the attached form and mail it directly to the SJC Dental Hygiene Program. Please use
one form for each instructor. You may copy this form as necessary. Please include the Course ID,
Section Number, Course Title, and the Number of Credits.
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In Progress Grade Report Form
Dear Professor,
Your student is applying for the SJC Dental Hygiene Program and has asked you to forward their in
progress grade in your course as part of the Application Process. Please fill out the form below and
mail this letter directly to the SJC Dental Hygiene Program by April 7, 2016. Please include the
Course ID, Section Number, Course Title, and the Number of Credits.
Thank you very much for your assistance.
________________________________________________________________________
(Student Name)
is currently enrolled in
__________________________________________________
(Course ID and Section #, Example: ENGL 111-001)
__________________________________________________
(Course Title, Example: Freshman Composition)
_________________________
(# of Credits, Example: 3)
at
________________________________________________________________________
(Name of Institution)
His/Her current grade is: ______________________________
Instructor’s Name: ________________________________________________________________________
Instructor’s Signature: _____________________________________________________________________
Date: _______________________________________
Please mail to:
San Juan College
Dental Hygiene Department
4601 College Blvd.
Farmington, NM 87402
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Section D – Previous Dental Experience
Please list work experiences related to Dental Health Care.
Employment verification letters must be attached to the application.
Job Title
Employer’s Name, Address & Phone Number
Name
Dates of Employment
Hrs/wk worked
Month/Year to Month/Year
Street
City
State
Zip Code
Phone
List Job Responsibilities
Job Title
Employer’s Name, Address & Phone Number
Name
Dates of Employment
Hrs/wk worked
Month/Year to Month/Year
Street
City
State
Zip Code
Phone
List Job Responsibilities
Job Title
Employer’s Name, Address & Phone Number
Name
Dates of Employment
Hrs/wk worked
Month/Year to Month/Year
Street
City
State
Zip Code
Phone
List Job Responsibilities
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Section E – Observation Hours
Please observe 3 dental hygienists, 4 hours each, at 3 different dental offices. Please ask the
hygienists the following questions and record their responses. Please dress in professional attire and
closed shoes.
If you have previously applied to the SJC Dental Hygiene Program, you do not need to resubmit your
observation hours.
Applicant’s Name
Affix Dental Office Business Card Here
Name of Dental Office
Date of Observation
Name of Dental Hygienist
Applicant Observed
Applicant-Observe and Record
1)
What is the best part of your job?
2)
What is the worst part of your job?
3)
What is your average daily routine?
4)
Notes:
Dental Hygienists Notes
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Section E – Observation Hours
Please observe 3 dental hygienists, 4 hours each, at 3 different dental offices. Please ask the
hygienists the following questions and record their responses. Please dress in professional attire and
closed shoes.
If you have previously applied to the SJC Dental Hygiene Program, you do not need to resubmit your
observation hours.
Applicant’s Name
Affix Dental Office Business Card Here
Name of Dental Office
Date of Observation
Name of Dental Hygienist
Applicant Observed
Applicant-Observe and Record
1)
What is the best part of your job?
2)
What is the worst part of your job?
3)
What is your average daily routine?
4)
Notes:
Dental Hygienists Notes
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Section E – Observation Hours
Please observe 3 dental hygienists, 4 hours each, at 3 different dental offices. Please ask the
hygienists the following questions and record their responses. Please dress in professional attire and
closed shoes.
If you have previously applied to the SJC Dental Hygiene Program, you do not need to resubmit your
observation hours.
Applicant’s Name
Affix Dental Office Business Card Here
Name of Dental Office
Date of Observation
Name of Dental Hygienist
Applicant Observed
Applicant-Observe and Record
1)
What is the best part of your job?
2)
What is the worst part of your job?
3)
What is your average daily routine?
4)
Notes:
Dental Hygienists Notes
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Section F – Essays
Please complete each of the 3 essay questions. Each essay must be a maximum of 500 words, double
spaced, and typed in 12 point font. Place your San Juan College ID number and the question number
only at the top right of each essay page as identifiers. (Example: 1234567, Question #1). Each essay
will be evaluated, on an anonymous basis, by faculty from the San Juan College Humanities
Department. Essays are evaluated based on;
 Critical Thinking
 Ethical Decision Making
 Writing Skill
o Organization of Content
o Vocabulary and Sentence Fluency
o Elaboration of Ideas
Question #1
Have you ever struggled for something and failed? How did you respond? Have you experienced
a feeling of disappointment and dissatisfaction of yourself?
Question #2
Evaluate a significant experience, risk you have taken, or ethical dilemma you have faced and its
impact on you.
Question #3
Write about a book that has special significance for you and explain why.
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Section G: The ACT
Please have your ACT scores sent directly to San Juan College Office of Admissions and include a
copy of your ACT scores with your application by the application deadline.
The ACT
2015-2016

Registration
o Online registration is the fastest method. You will know immediately if your preferred test
center has space for you to test, and you can print your admission ticket from the website.
Register online at www.actstudent.org/regist

Test Center in Farmington, NM
o San Juan College, Code: 026370
o Testing Centers outside of Farmington, NM are available. For more information please visit
www.actstudent.org/regist/centers

ACT Scores
o Please have your ACT scores sent directly to San Juan College Office of Admissions and include
a copy of your ACT scores with your application.
o The San Juan College code is: 2637.

ACT Fee
o ACT (No Writing): $39.50 Includes reports for you and up to four college choices (if valid codes
are provided when you register). All fees are nonrefundable unless otherwise noted.
Additional registration fees may apply. Please visit www.actstudent.org/regist/actfees.html for
more information.

Retake the ACT Test
o Students can take the ACT up to 12 times total.

Expiration Date on ACT Scores
o The Dental Hygiene Program will accept ACT Scores, regardless of date taken.

Test Dates at San Juan College
Test Date
Registration Deadline
October 24, 2015
September 18, 2015
December 12, 2015
November 6, 2015
February 6, 2016
January 8, 2016
April 9, 2016
March 4, 2016
June 11, 2016
May 6, 2016
Late Fee Required
September 19-October 2, 2015
November 7-20, 2015
January 9-15, 2016
March 5-18, 2016
May 7-20, 2016
*Test dates are on Saturday unless otherwise noted.
**SPECIAL NOTE: Non-Saturday testing is available only for student who cannot test on a Saturday because of religious
convictions. If there is a non-Saturday test center within 75 miles of your home for any test date, register for that date and
request that center.

For more information please visit www.actstudent.org or call (319) 337-1270.
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Section H - Acknowledgement

I have read and understand what is required for the SJC Dental Hygiene Program application
process.
 I know to contact the SJC Dental Hygiene Program, if I have any questions about applying.
 I understand the deadline for this application process is Thursday, April 7, 2016 at 5:00 p.m.
 I understand that if required information is not included with my application for the SJC
Dental Hygiene Program my application will not be considered.
 I understand that admission to the SJC Dental Hygiene Program is competitive and that
applicants are assessed and ranked.
The SJC Dental Hygiene Program requires students to do a criminal background check. Acceptance
into the SJC Dental Hygiene Program is conditional upon a Certified Background Investigation
following selection. The ability to participate in required off-sight clinical activities and to obtain a
professional license may be dependent upon a criminal background check.
Race/Ethnicity (optional)
The Program gathers race/ethnicity data for information purposes only and to meet accreditation
standards for access and equity. Answering the race/ethnicity question is optional and in no way
affects your application.
 White, Non-Hispanic
 Black, Non-Hispanic
 Hispanic
 American Indian or Alaskan Native
 Asian or Pacific Islander
 Unknown Race/Ethnicity
 Other: ____________________
I certify this application to be true and correct and that I am solely responsible for my answers. By
signing below, I give San Juan College permission to conduct a criminal background check. Any
false statements knowingly submitted will result in my being removed from consideration for
acceptance into the Program and is grounds for dismissal from the Program.
________________________________________________________________________________
Printed Full Name
________________________________________________________________________________
Signature
__________________________________
Date
MAKE AND KEEP A COPY OF THIS APPLICATION FORM FOR YOUR RECORDS.
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