ATTENDEE REGISTRATION FORM
April 26-27 , 2013 Hotel Hershey
NAME NICKNAME FOR BADGE
Please fill out this form and return by March 18 , 2013 , even if you will not be attending any social events . Return to :
PDA Annual Session P . O . Box 3341 Harrisburg , PA 17105 Fax : ( 717 ) 232-7169 OR Register via the PDA website at www . padental . org / as
SPOUSE / GUEST ( IF ATTENDING ) |
NICKNAME FOR BADGE |
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ADDRESS
CITY
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STATE |
ZIP |
PHONE ( WORK ) |
FAX |
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SPECIAL DIETARY / ACCESSIBILITY NEEDS |
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Mark the appropriate line with “ M ” for yourself and “ S ” for spouse . ____ PDA Member ( District #______ ) ____ ASDA Member ____ APDA Member ( Alliance ) ____ Guest I am a : q PDA Delegate q PDA Alternate Delegate
Please help us spend our resources wisely by indicating your attendance plans below . |
Event Date |
Event |
# Attending |
Cost |
Total |
Thursday , April 25 |
Optimal Aging CE Lecture |
_____ X |
Complimentary |
|
Friday , April 26 |
Luncheon for Delegates and Alternates ( sponsored by PDAIS ) |
_____ X |
Complimentary for |
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Use zero if you are not attending |
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delegates & alternates |
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Friday , April 26 |
PADPAC and Alumni Receptions |
_____ X |
Complimentary |
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Open to all attendees , spouses and guests ; business casual dress code |
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Saturday , April 27 |
Fun Run / Walk — Circle T-shirt size : M L XL XXL |
_____ X |
$ 15 |
= ________ |
Saturday , April 27 |
Luncheon for Delegates and Alternates ( sponsored by PDAIS ) |
_____ X |
Complimentary for |
|
Use zero if you are not attending |
|
delegates & alternates |
Saturday , April 27 |
President ’ s Reception and Dinner Dance |
_____ X |
$ 85 |
= ________ |
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Please indicate each attendee ’ s meal choice : |
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( ___ ) Filet of Beef |
( ___ ) Salmon |
( ___ ) Vegetarian |
Children age 12 and under ( chicken tenders ) |
_____ X |
$ 30 |
= ________ |
Sponsor a Dental Student Leader |
_____ X |
$ 85 |
= ________ |
Method of Payment — Please make check payable to : 2013 PDA Annual Session |
Total Enclosed |
$ |
q Check |
q MasterCard |
q VISA |
q American Express |
q Discover |
CARD NUMBER EXP . DATE SIGNATURE
Sponsor a Dental Student Leader ASDA delegates and alternates , with financial support from PDA , attend Annual Session to participate in our governance structure while representing the interests of ASDA . PDA has welcomed other dental students , beyond the ASDA delegation , to the meeting . These students have an interest in organized dentistry and PDA is asking for your financial assistance to support their attendance at the meeting . Please consider sponsoring a dental student member . Funding will be used to offset the cost of meals for dental students .
President ’ s Reception and Dinner Dance on April 27 Please join us to honor the outgoing president , Dr . Bernie Dishler and his wife , Lana , and enjoy an evening of Klezmer music and the musical variety of a DJ . Klezmer music , or “ Jewish Jazz ,” is the traditional dance and instrumental music of eastern European Jews that is played on celebratory occasions . Sponsored in part by the Pennsylvania Society of Oral and Maxillofacial Surgeons , the Second District Valley Forge Dental Association , Thayer Dental Laboratory and the Montgomery Bucks Dental Society .
Cancellations must be received , in writing , by April 5 , 2013 , in order to obtain a refund . NO on-site ticket sales .
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J A N / F E B 2 0 1 3 | P E N N S Y LVA N I A D E N TA L J O U R N A L