REGISTRATION FORM Pennsylvania’ s Dental Meeting | April 17-18, 2026
REGISTRATION FORM Pennsylvania’ s Dental Meeting | April 17-18, 2026
( 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 Dental Student / Resident Please provide the name of the dental school / 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
ACTIVITIES
The registration fees for activities are in addition to the Full Day and Half Day registration fees.
Sponsor a Dental Student Help defray the cost PDA pays to host a dental student at the meeting.
m $ 80 per student _______ = _______
Thursday, April 16, 2026, 7:00 p. m. – 8:30 p. m. Meet Your PDA Leaders Reception – open to all PDA members and their guests. Join your reception hosts, PDA president, Ted Rockwell; PDA president-elect, Jim Mancini and ADA trustee, Jim Tauberg for drinks and dialog. Dress code is casual.
No charge per attendee but please indicate how many will attend the event _______
Thursday, April 16, 2026, 8:30 p. m. – 10:00 p. m. Fire Pit Gathering – If it’ s not raining, join us at the fire pit for camaraderie and s’ mores. Drinks are available for purchase at Frontier Tavern. Dress code is casual.
No charge per attendee but please indicate how many will attend the event _______
Friday, April 17, 2026, 6:00 p. m. – 7:00 p. m. Welcome Reception –($ 45 per person) – mix & mingle with friends and colleagues before dinner. Dress code is business attire.
m $ 45 per attendee x _______ = _______
Friday, April 17, 2026, 7:00 p. m. – 10:00 p. m. Member’ s Celebration and Awards Dinner($ 90 per person) – open to all PDA members and their guests. The dinner will recognize those making an impact on our profession, including PDA’ s outgoing president, Dr. Ted Rockwell; PDA board members who have completed their term of service and the 2026 winners of PDA’ s Distinguished Service, Recognition and Public Service awards. Dress code is business attire.
m $ 90 per attendee x _______ = _______
Please indicate the number of attendees selecting each entree. Use zero if no one has selected that entree.
_____ Chicken _____ Salmon _____ Vegetarian
Saturday, April 18, 2026, 11:45 a. m. – 1:15 p. m. PDA Former Presidents’ Luncheon – Open to PDA members who have served as president of the organization. _______ No charge for current and former PDA presidents.
Saturday, April 18, 2026, 4:30 p. m. – 5:30 p. m. Reception($ 25 per person) – Open to members of the Pierre Fauchard Academy; the American College of Dentists and the International College of Dentists, USA Section, District 3 and their guests. Dress code is business casual.
m $ 25 per attendee x _______ = _______
JANUARY / FEBRUARY 2026 | PENNSYLVANIA DENTAL JOURNAL 15