P E N N S Y LVA N I A’ S
Dental Meeting
APRIL 21-22, 2017
Registration Form (one form per person, please)
FULL NAME:
NICKNAME (FOR BADGE):
ADDRESS:
STATE:
CITY:
ZIP:
PHONE: EMAIL:
DESCRIBE ANY DIETARY ALLERGIES OR ACCESSIBILITY NEEDS:
Please check one:
Additional Attendees NOT attending courses or the exhibit hall
will need a name badge. Please list additional attendees:
m PDA Member Dentist
m Dental Hygienist
m ADA Member Dentist
m Dental Assistant
FULL NAME
NICKNAME
m Non-Member Dentist
m Non-Licensed
Office Staff
FULL NAME
NICKNAME
EVENTS
Welcome Reception at Troegs Brewery
Thursday, April 20 @ 6:30 p.m.
$56 per attendee x _______ = _______
Additional Friday Lunch Tickets
(included with full-day CE course, hands-on program)
$45 per attendee x _______ = _______
Night at the Museum: The Hershey Story
Saturday, April 22 @ 6:30 p.m.
$65 per attendee x _______ = _______
Additional Saturday Lunch Tickets
(included with full-day CE course)
$45 per attendee x _______ = _______
Luncheon with Wine Tasting
Hosted by APDA on Friday, April 21 @ 1:00 p.m.
$80 per attendee x_______ = _______
Dental Student Funding
Help bring a dental student to the meeting.
$75 per day, per student = _______
Please indicate each attendee’s meal choice:
_______ Pork or ________ Salmon
N O V / D E C 2 0 1 6 | P E N N S Y LVA N I A D E N TA L J O U R N A L
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