Application Form – Expanded Function Restorative Education Program

Full Name(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone

Birthday

Are you a registered dental hygienist?

Yes

What state are you licensed in?

If in Washington, what license type do you have?

Graduation Date

National board exam you intend to take

CRDTS

WREB

Unknown

Have you read the requirements of the course and are you able to attend 2 weeks of online lectures prior to the in person start date of 6/12/24?

The mandatory online lectures will be scheduled for 5pm-7pm on the following dates: 5/28, 5/29, 5/30, 6/4, 6/5, 6/6.

Yes

Are you able to travel to Spokane, WA and stay for the duration of the course 6/12-6/19?

Yes

This field is for validation purposes and should be left unchanged.