2018 PENNSYLVANIA’S DENTAL MEETING
REGISTRATION FORM (one form per person, please)
FULL NAME: NICKNAME (FOR BADGE):
ADDRESS: STATE: ZIP:
CITY:
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
FULL NAME NICKNAME
FULL NAME NICKNAME
SOCIAL EVENTS
Welcome Reception Sponsored by PADPAC
mix & mingle with friends, colleagues, PA legislators
and officials from the Governor’s Administration.
Dress code is business attire. Trolley Tour of Hershey
Hosted by APDA on Saturday, April 28 @ 1:30 p.m.
$20 per attendee x _______ = _______
Friday, April 27 @ 6:00 p.m.
$20 per attendee x _______ = _______ Additional Friday Lunch Tickets
(included with registration for Anesthesia or
Act 124 CE courses)
$45 per attendee x _______ = _______
150 th Anniversary Gala Sponsored in part by
PSOMS and TDIC
relive and celebrate 150 years of PDA history while
you enjoy the reception, dinner and entertainment.
Dress code is black-tie or a dark suit.
Saturday, April 28 @ 7:00 p.m.
$90 per attendee x _______ = _______
Please indicate each attendee’s meal choice:
____ Beef ____ Salmon ____ Vegetarian
Champagne Luncheon & Cooking Demonstration
Hosted by APDA on Friday, April 27 @ 1:00 p.m.
$80 per attendee x _______ = _______
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Additional Attendees NOT attending courses or
the exhibit hall will need a name badge. Please list
additional attendees:
NOV E M B E R/DE CE M BER 2017 | P EN N S YLVA N IA D EN TA L J O UR NAL
Additional Saturday Lunch Tickets
(included with registration for Dr. Levin’s lecture)
$45 per attendee x _______ = _______
Dental Student Funding
Help bring a dental student to the meeting.
$75 per student x _______ = _______