REGISTRATION FORM
PDA ’ s Family Vacation Dental Conference June 15-17 , 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 Dental Hygienist
|
m ADA Member Dentist
m Dental Assistant
|
m Non-Member Dentist
m Non-Licensed Office Staff
|
m Dentists enrolled in a Residency Program |
Spouses and guests NOT attending courses will need a name badge . Please list additional attendees and ages for children or grandchildren under the age of 18 :
FULL NAME NICKNAME AGE ( IF THE GUEST IS UNDER 18 )
FULL NAME NICKNAME AGE ( IF THE GUEST IS UNDER 18 )
FULL NAME NICKNAME AGE ( IF THE GUEST IS UNDER 18 )
FULL NAME NICKNAME AGE ( IF THE GUEST IS UNDER 18 )
FULL NAME NICKNAME AGE ( IF THE GUEST IS UNDER 18 )
Full Conference Package includes CE on Thursday , Friday and Saturday , breakfast and breaks each morning and one ( 1 ) ticket to attend the Welcome Reception at 5:00 p . m . on Friday , June 17 . Additional tickets are available for purchase .
m $ 350 for PDA / ADA Member Dentists m $ 250 for PDA / ADA New Dentists and Residents m $ 500 for Non-member Dentists
m $ 315 for PDA Life and Retired Member Dentists , Hygienists , Assistants , EFDAs , Non-Licensed Staff and Guests
Additional Welcome Reception Tickets for Family and Friends Friday , June 16 , 2023 , 5:00 p . m . – 6:30 p . m .
Welcome Reception – attend with your family and meet other attendees and their families . Variety of heavy hors d ’ oeuvres , open bar and kid friendly options for food and beverages . Dress code is casual .
$ 50 per guest x ______ = ______
$ 35 per child ages 4-12 ( children ages 3 and under are complimentary ) x ______= ______
Total Due $_______________________________
Method of Payment
Please make check payable to : PDA and mail with completed form to P . O . Box 3341 , Harrisburg , PA 17105 or fax your registration to ( 717 ) 232-7169 or register online at www . padental . org / VacationCE
m Check m MasterCard m Visa m American Express m Discover
CARD NUMBER EXP . DATE
Registrations accepted until June 6 , 2023 . Cancellations must be received in writing by June 8 , 2023 . No refunds will be issued for registrations cancelled after June 8 . Cancellations can be faxed to ( 717 ) 232-7169 or emailed to rvn @ padental . org .
Questions ?
Contact Rebecca Von Nieda at ( 717 ) 234-5941 , ext . 117 or rvn @ padental . org .
SIGNATURE
PRINT NAME AS IT APPEARS ON THE CARD
30 MARCH / APRIL 2023 | PENNSYLVANIA DENTAL JOURNAL