REGISTRATION FORM Pennsylvania ’ s Dental Meeting | April 19-20 , 2024
REGISTRATION FORM Pennsylvania ’ s Dental Meeting | April 19-20 , 2024
( 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 Please provide the name of the residency program 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
( registrations for social events are NOT part of either conference registration package )
Sponsor a Dental Student Help underwrite the cost PDA pays to host a dental student at the meeting .
m $ 75 per student x _______ = _______
Thursday , April 18 , 2024 , 6:00 p . m . – 7:30 p . m . Meet Your ADA Trustee Reception – with Dr . Jim Boyle . Open to all members and their guests ; not just member dentists attending the meeting .
Dress code is business casual .
No charge per attendee but please indicate how many will attend the event _______
Friday , April 19 , 2024 , 6:00 p . m . – 7:00 p . m . Welcome Reception – mix and mingle before the awards dinner . Open to all members and their guests ; not just member dentists attending the meeting .
Dress code is business attire . m $ 40 per attendee x _______ = _______
Friday , April 19 , 2024 , 7:00 p . m . – 10:00 p . m . Member ’ s Celebration and Awards Dinner – open to all PDA members and their guests . The dinner will recognize PDA ’ s outgoing president , Dr . Richard R . Grossman ; PDA board members and the 2024 winners of PDA ’ s Distinguished Service , Recognition and Public Service awards .
Dress code is business attire . m $ 75 per attendee x _______ = _______
Saturday , April 20 , 2024 , 4:45 p . m . – 5:45 p . m . Reception – open to members of the Pierre Fauchard Academy ; the Philadelphia-Delaware Valley Section of the American College of Dentists and the International College of Dentists , USA Section , District 3 and their guests .
Dress code is business casual . m $ 20 per attendee x _______ = _______
JANUARY / FEBRUARY 2024 | PENNSYLVANIA DENTAL JOURNAL 27