Dental Health Summer Institute

Brought to you by ODU's Gene W. Hirschfeld School of Dental Hygiene and Delta Dental of Virginia.

Thank you for your interest in the Dental Health Summer Institute! There are two sections to this application. You cannot save the application and come back to it, so please print a copy of the application, review it and make sure you have everything you need BEFORE you get started. Fill out the form below to submit an application. This application will require you to upload an unofficial high school transcript and brief personal essay.

If you have any further questions, please email abruhn@odu.edu or call 757-683-3338.

1Personal Information > 2Academic History and Interests
Applicant's Name Applicant's Name * First Middle Last
Preferred First Name
Date of Birth Date of Birth * / MM / DD YYYY
What was your sex at birth? *
Do you consider yourself to be of Hispanic/Latino
origin? *
What is your race? (Choose one or more) *

What is your race? (Choose one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Applicant's Contact Information
Email *
Phone Phone * - ### - ### ####
Applicant's Mailing Address
Street Address Line 1 *
Street Address Line 2
City *
State *
Postal/Zip Code *
REQUIRED Primary Parent/Guardian Information

This is the description of your section break.
Primary Parent/Guardian Name (REQUIRED) Primary Parent/Guardian Name (REQUIRED) * First Last
Parent/Guardian Phone Number Parent/Guardian Phone Number * - ### - ### ####
Parent/Guardian Email Address *
What time of the day is best to contact the Parent/Guardian? What time of the day is best to contact the Parent/Guardian? * : HH MM AM/PM
Which is the preferred method to contact the Parent/Guardian? *
OPTIONAL Second Parent/Guardian Information

This is the description of your section break.
Second Parent/Guardian Name (OPTIONAL) Second Parent/Guardian Name (OPTIONAL) First Last
Second Parent/Guardian Phone Number Second Parent/Guardian Phone Number - ### - ### ####
Second Parent/Guardian Email Address
What time of the day is best to contact the second Parent/Guardian? What time of the day is best to contact the second Parent/Guardian? : HH MM AM/PM
Which is the preferred method to contact the second Parent/Guardian?

Dental Health Summer Institute

Dental Health Summer Institute

Applicant's Contact Information

Applicant's Mailing Address

REQUIRED Primary Parent/Guardian Information

OPTIONAL Second Parent/Guardian Information