Living Your Best Life Inside and Outside of Dentistry
REGISTRATION FORM Pennsylvania ’ s Dental Meeting | April 28-29 , 2023
( one form per person , please )
FULL NAME : NICKNAME ( FOR BADGE ):
ADDRESS : CITY : STATE : ZIP :
PHONE : EMAIL :
DESCRIBE ANY DIETARY ALLERGIES OR ACCESSIBILITY NEEDS :
Please check one : m PDA Member Dentist
m ADA Member Dentist m Non-Member Dentist m Dental Hygienist m Dental Assistant
m Non-Licensed Office Staff m Resident / Dental Student Please provide the name of the residency program or dental school that you are currently enrolled in :
___________________________________________
Spouses and guests NOT attending courses will need a name badge . Please list additional attendees :
FULL NAME NICKNAME
FULL NAME
NICKNAME
SOCIAL EVENTS
See Social Events section for more details
Sponsor a Dental Student Help underwrite the cost PDA pays to host a dental student at the meeting .
m $ 99 per student _______ = _______
Friday , April 28 , 2023 , 6:30 p . m . – 7:30 p . m . Friday Reception – with keynote speaker , Marko Vujicic , PhD , Chief Economist & Vice President , ADA ’ s Health Policy Institute . Open to all members and their guests ; not just member dentists attending the meeting .
Dress code is business casual . m $ 65 per attendee x _______ = _______
Saturday , April 29 , 2023 , 5:30 p . m . – 8:30 p . m . Saturday Reception – Reception at Conshohocken Brewing Co . located at 3 Dekalb Street , Bridgeport , PA 19405 . Open to all members and their guests ; not just member dentists attending the meeting .
Dress code is casual . m $ 40 per attendee x _______ = _______
Sunday , April 30 , 2023 , 9:30 a . m . – 11:00 a . m . Sunday Brunch for Women Dentists – socialize with your peers in a private room at The Farmer ’ s Daughter Restaurant . Open to all women dentists ; not just those attending the meeting .
Dress code is casual . m $ 60 per attendee x _______ = _______
28 JANUARY / FEBRUARY 2023 | PENNSYLVANIA DENTAL JOURNAL