PDA ’ s Family Vacation Dental Conference August 15-17 , 2024

( one form per person , please )

FULL NAME : NICKNAME ( FOR BADGE ):

ADDRESS : CITY : STATE : ZIP :

PHONE : EMAIL :

DESCRIBE ANY DIETARY ALLERGIES OR ACCESSIBILITY NEEDS :

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 Conference Package includes CE on Thursday , Friday and Saturday , breakfast each morning and one ( 1 ) ticket to attend the Welcome Reception at 5:00 p . m . on Friday , August 16 . Additional tickets are available for purchase . m $ 399 for PDA / ADA Member Dentists m $ 299 for PDA / ADA New Dentists or Residents m $ 550 for Non-member Dentists m $ 315 for PDA Life and Retired Member Dentists , Hygienists ,

Assistants , EFDAs , Non-Licensed Staff and Guests

Or , select individual courses and purchase a ticket for the Welcome Reception . m $ 185 Antibiotic Guidance on August 15 m $ 185 Posterior Composites and Crown Cementation on August 16 m $ 185 Cannabis , Cannabinoids and Terpenes on August 17 Individual courses are $ 299 each for non-member dentists

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

m Check m MasterCard m Visa m American Express m Discover

CARD NUMBER

SIGNATURE

EXP . DATE

Additional Welcome Reception Tickets for Family and Friends Friday , August 16 , 2024 , 5:00 p . m . – 6:30 p . m .

Welcome Reception – attend with your family and meet other attendees and their families . Light hors d ’ oeuvres , open bar and kid friendly options for food and beverages . Dress code is casual .

$ 65 per guest x ______ = ______

$ 35 per child ages 6-12 ( children ages 5 and under are complimentary ) x ______= ______

Total Due $_______________________________

Registrations accepted until August 5 , 2024 . Cancellations must be received in writing by August 7 , 2024 . No refunds will be issued for registrations cancelled after August 7 . 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 .

PRINT NAME AS IT APPEARS ON THE CARD

16 MARCH / APRIL 2024 | PENNSYLVANIA DENTAL JOURNAL