Scda 2015 reg form (v1)
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This document is a registration form for the 27th Annual Meeting on Special Care Dentistry hosted by the Special Care Dentistry Association (SCDA) from March 27-29, 2015 in Denver, Colorado. The form requests information from attendees such as contact details, membership status, dietary restrictions, registration fees, and payment methods. Registration includes access to educational sessions, meals and networking events. Fees range from $225 for students to $975 for dentist non-members, depending on member status and date of registration. The form also allows attendees to enroll or renew SCDA membership and register guests.
Scda 2015 reg form (v1)
- 1. 1. Attendee Information ❑ Dr. ❑ Mr. ❑ Ms. First Name Last Name Credential(s) Company Mailing Address City State ZIP Country Phone Fax E-mail Are you a member of SCDA? ❑ Yes ❑ No Is this your first SCDA Annual Meeting? ❑ Yes ❑ No How did you hear about this event? ❑ www.SCDAonline.org ❑ E-mail ❑ Word of Mouth ❑ Personal Invitation ❑ Printed Brochure ❑ Past Attendee Are you interested in attending the SCDA mentor program for new members and students? ❑ Yes ❑ No Are you interested in being a session moderator? ❑ Yes ❑ No If yes, do you have a preferred session? What specific type of dentistry do you practice? ❑ Geriatric ❑ Pediatric ❑ Hospital ❑ Other What is your average patient base per year? 2. ADA Information Do you have any special dietary restrictions? ❑ Yes ❑ No ________________________________________________________________ If due to a disability you have any special needs, please contact SCDA at 312.527.6764 or SCDA@SCDAonline.org. 3. Registration Fees Registration includes access to all educational sessions, meals and networking functions. Early Regular (Before 1/23/15) (After 1/23/15) Dentist Member ❑ $695 ❑ $795 Dentist Non-member ❑ $875 ❑ $975 One-day Member ❑ $450 ❑ $550 ❑ Friday ❑ Saturday ❑ Sunday One-day Non-member ❑ $550 ❑ $650 ❑ Friday ❑ Saturday ❑ Sunday Student/Resident ❑ $225 ❑ $225 Non-dentist Member ❑ $425 ❑ $525 (Hygienist, Manager,Allied Health) Non-dentist Non-member ❑ $525 ❑ $625 (Hygienist, Manager,Allied Health) Registration Fees Due $ 4. Guest Registration ❑ $200 Includes continental breakfast for 3 days, the Friday and Saturday night receptions and access to the exhibitors First Name Last Name 5. Membership Enrollment/Renewal Options If you would like to renew your SCDA membership or become a member for the first time, please check one of the following options: ❑ New Dentist (full year) $320 ❑ Hygienist $235 ❑ Dentist Renewal $350 ❑ Manager/Other Non-dentist or ❑ Student $80 Non-hygenist Dental Profession $235 ❑ Resident $105 ❑ Supporting Member $230 ❑ Fellowship Maintenance Fee ❑ Diplomate Maintenance Fee (if applicable) $60 (if applicable) $100 Membership Dues $ 6. Payment Information Total Payment Due: $____________ Payment Method: ❑ Check Mail check made out to SCDA with copy of registration form to: Special Care Dentistry Association 8258 Solutions Center Chicago, IL 60677-8002 ❑ Credit Card (Please do not provide credit card information on this form.) Upon receipt of this registration form,SCDA will email an invoice with credit card processing information (Visa and MasterCard accepted). Please provide email address to send credit card processing information to: Fax or email registration form to: 312.673.6663 or registration@SCDAonline.org The 27th Annual Meeting on Special Care Dentistry March 27–29, 2015 | Grand Hyatt Denver | Denver, Colorado Attendee Registration Form Cancellation Policy: The registration fee, less a $100 processing fee, is refundable if request is received in writing by January 30, 2015. No refunds after January 30, 2015. Register online at www.SCDAonline.org! SCDA also offers convenient online registration. Simply visit www.SCDAonline.org. *SCDA’s online registration system accepts credit card payments only. Visa and MasterCard accepted. **Please note that non-members will need to join as a “Guest” member before completing online registration.