1 4 6 t h A n n u a l S e s s i o n
Attendee Registration Form
April 25-26 , 2014 Hotel Hershey
NAME NICKNAME FOR BADGE
Please fill out this form and return by March 20 , 2014 , 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 / calendar
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 : ❑ PDA Delegate ❑ PDA Alternate Delegate
Please help us spend our resources wisely by indicating your attendance plans below . |
Event Date |
Event |
# Attending |
Cost |
Total |
Thursday , April 24 |
Global Conflict CE Lecture at 1:00 PM |
_____ X |
Complimentary |
|
Thursday , April 24 |
Endodontics CE Lecture at 3:00 PM |
_____ X |
Complimentary |
|
Friday , April 25 |
Luncheon for Delegates and Alternates ( sponsored by PDAIS ) |
_____ X |
Complimentary for |
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|
Use zero if you are not attending |
|
delegates & alternates |
|
Friday , April 25 |
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 26 |
Fun Run / Walk — Circle T-shirt size : S M L XL XXL |
_____ X |
$ 15 |
= ________ |
Saturday , April 26 |
Luncheon for Delegates and Alternates ( sponsored by PDAIS ) |
_____ X |
Complimentary for |
|
Use zero if you are not attending |
delegates & alternates |
Saturday , April 26 |
President ’ s Reception and Dinner |
_____ X |
$ 80 |
= ________ |
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Please indicate each attendee ’ s meal choice : ( ___ ) Chicken Breast Stuffed w / Artichokes , Spinach and Goat Cheese |
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( ___ ) Swordfish |
( ___ ) 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 : 2014 PDA Annual Session
❑ Check ❑ MasterCard ❑ VISA ❑ American Express ❑ Discover Total Enclosed
$
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 on April 26 Dr . Hoffman invites you and your family to attend the President ’ s Reception and Dinner on Saturday . The evening will feature entertainment by Dueling Pianos — two professional piano players who sing and entertain . Humor and audience participation are prevalent ! Most of the songs performed are Rock and Roll , Classic Rock , Top 40 , R & B and Country , played by your request . So , not only will we honor our leaders and Dr . Hoffman , but we will clap , sing , eat and have a great evening of fun ! Sponsored in part by the Pennsylvania Society of Oral and Maxillofacial Surgeons , the Dental Society of Western PA and Thayer Dental Laboratory . The dress code is business attire .
Cancellations must be received , in writing , by April 4 , 2014 , in order to obtain a refund . NO on-site ticket sales .
1 8 J A N / F E B 2 0 1 4 | P E N N S Y LVA N I A D E N TA L J O U R N A L