Registration Form
( one form per person, please)
PDA’ s Family Vacation Dental Conference August 14-16, 2025
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 |
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 each morning and one( 1) ticket to attend the Welcome Reception at 5:00 p. m. on Friday, August 15. Additional tickets are available for purchase.
m $ 399 for PDA Member Dentists m $ 299 for PDA / ADA New Dentists, Residents and Dental Students m $ 599 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. Courses are $ 185 each for member dentists and non-dentist staff / guests or $ 299 each for non-member dentists
m Sedation & Emergencies on 8 / 14 m TMD & Orofacial Pain on 8 / 15 m Pain & Opioid Prescribing on 8 / 16
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
SIGNATURE
EXP. DATE
Firepit Dessert Reception, 9:00 p. m. on 8 / 14 – Complimentary event sponsored by PDA Member Advantage, A PERC program exclusively for PDA members. Dress code is casual. Indicate # of attendees: ____
Additional Welcome Reception Tickets for Family and Friends, 5:00 p. m. on 8 / 15 – light hors d’ oeuvres, open bar and kid friendly options for food and beverages. Dress code is casual. One( 1) ticket is included with each full conference package registration. Order additional tickets for attendees 7 years of age and older( children ages 6 and under are complimentary):
$ 65 per guest aged 21 + x ______ = ______ $ 45 per guest ages 14-20 x ______= ______ $ 35 per guest ages 7-13 x ______= ______
Total Due $_______________________________
Registrations accepted until August 7, 2025.
Cancellations must be received in writing by August 8, 2025. No refunds will be issued for registrations cancelled after August 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.
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PRINT NAME AS IT APPEARS ON THE CARD MAY / JUNE 2025 | PENNSYLVANIA DENTAL JOURNAL