Registration Form (one form per person, please)
P E N N S Y LVA N I A’ S D E N TA L M E E T I N G – A P R I L 6 , 2 0 1 9
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
Additional Attendees NOT attending courses or
the exhibit hall will need a name badge. Please list
additional attendees:
FULL NAME NICKNAME
FULL NAME
NICKNAME
SOCIAL EVENTS
Friday, April 5, 2019
8:30 p.m. – 10:30 p.m
Welcome Reception
mix & mingle with friends and colleagues
from across the Commonwealth. Dress
code is business casual. Indicate your
attendance plans in the chart and add
the fee to your total.
Friday, April 5, 2019,
7:00 p.m. – 9:30 p.m.
Board of Trustees’ Dinner
Join PDA for a plated dinner honoring
those making an impact on our profession.
Honorees include PDA’s outgoing president;
board members who have completed their
term of service and the 2019 PDA award
winners. Dress code is business attire.
$75 per attendee x _______ = _______
Please indicate each attendee’s meal choice:
____ Chicken
____ Salmon
____ Vegetarian
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NOV E M B E R/DE CE M BER 2018 | P EN N S YLVA N IA D EN TA L J O UR NAL
Dental Student Funding
Help bring a dental student to the meeting.
$75 per student x _______ = _______