Supportive Pathway Program - Supervising Dentist Application

Thank you for your interest in volunteering as a Supervising Dentist in the CDSA’s Supportive Pathway Program. This application helps the College confirm eligibility and ensure participating practices can provide a supportive, supervised learning environment.

Applicant Information

Name(Required)

First Last

CDSA Registration Number

Practice Name(Required)

Practice Address(Required)

Street Address Address Line 2 City

Email(Required)

Phone

Eligibility Confirmation

Please confirm the following

I hold a current, unrestricted practice permit as a General Dentist in Alberta(Required)

Yes

I am in good standing with the College(Required)

Yes

I have been in practice for a minimum of five (5) years(Required)

Yes

Program Understanding

Please confirm your understanding of the Supportive Pathway Program

The initial placement is 2–4 weeks, unpaid, and focused on mentorship and orientation to Canadian dental practice culture.(Required)

I understand

That Dental Interns participate under a restricted practice permit that has some supervision requirements.(Required)

I understand

My practice environment supports learning and professional integration.(Required)

I agree

Acknowledgement

The initial placement is intended to be short term (2- to 4-weeks). Following the placement, if both the Supervising Dentist and Dental Intern are interested in continuing their working relationship, they may notify the CDSA and apply to extend the restricted practice permit for up to one (1) year. An approved extension allows the Dental Intern to continue gaining supervised experience and it affords the dental practice an additional team member to provide patient care.

Date(Required)

Signature(Required)

Supportive Pathway Program – Supervising Dentist Application