ADAARoundTable PreRegistrationForm2012_Midwinter


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2012 Chicago Midwinter Meeting ADAA Round Table Learning Pre-Registration Form

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ADAARoundTable PreRegistrationForm2012_Midwinter

  1. 1. Lear ning in the Round PRE–REGISTRATION DEADLINE Friday, February 17, 2012 ATTENDEES WILL BENEFIT FROM: • Product samples, education, door prizes, fellowship and fun. • 3 CEUs to be earned for each session. ADAA is designated as an Approved PACE Program Provider by the Academy of General Dentistry. This course has been approved for DANB CDE credit.Back by Popular Demand!Featuring New Products & New ManufacturersHave fun while you learn in this hands-on small group experience.Share ideas with other dental assistants in your group while you are introducedto new products and techniques that will benefit your practice.You will come away energized with new ideas, new colleagues and lots of prod-uct samples for your office.Where: McCormick Place Fees: West Hall, Room 181A $5 Per Session ADAA Members Members sign up for both sessions for $8!When: (2 Sessions*): $10 Per Session for E-Members & Non– FRIDAY, FEBRUARY 24, 2012 Members Session 1: 9 AM – Noon E-Members & Non-Members sign up for Session 2: 1:30 PM – 4:30 PM both sessions for $15 *Different topics will be covered (No refunds) in each session.PRE–REGISTRATION is not required but highly recommended. Preregistration begins November 1, 2011.Seating will be limited. Don’t miss this opportunity! 147th Chicago Midwinter Meeting Course Moderator: Jennifer K. Blake, CDA, EFDA, MADAA Jen Blake has been a member of the dental team for over 35 years. She has been a clinical assistant, educator, and is past president of the American Dental Assistants Association. Currently she is serving as ADAA Director of Education and Professional Relations. see next page for registration information Visit us at:
  2. 2. REGISTRATION INFORMATION By February 17, 2012, return this registration to:Fees: ADAA Members $5 per session ADAA Midwinter Meeting Members sign up for both sessions for $8! 35 East Wacker Drive, Suite 1730 Non–ADAA Members $10 per session Chicago IL 60601–2211 E-Members & Non-Members sign up for both Fax: 312–541–1496 — No telephone registration sessions for $15 (No refunds) Return form with check, money order or credit card information. We will not bill you. Faxed forms must include credit card informa- tion.* ADAA members should include a photocopy of their current American Dental Assistants Association membership card with faxed or mailed registration.147th Chicago Midwinter MeetingMcCormick Place — West Hall, Room 181A Registration is also available online Nov. 1, 2011 at change in location will be noted in the on-site program and in the Registration limited — sign up early. You will be notified by e–registration materials sent to pre–registered attendees. mail of your registration.Pre–Registration for ADAA Learning in the Round Learning in the Round – February 24, 2012Deadline: February 17, 2012Pre-registration strongly recommended. Courses will be closed once PLEASE PRINTmaximum registration has been achieved. Registration for this course Status (Circle One)is separate from CDS and is handled by ADAA only. ADAA Member E-Member Non-MemberPre–Registration for CDS Meeting � 2/24 AM session � 2/24 PM sessionBoth members and non-members who wish to register for the CDS 9:00–Noon 1:30–4:30 PMMeeting itself, including admission to the Exhibit Floor, should fill out CDS Meeting Registration forms and submit them with fee (if any) to CDS as directed on ADAA Membership Number All of those pre–registered with the CDS will receive badges during Name February in the mail. These registrants need only stop by the Chica-go Dental Society registration desk to pick up a plastic badge holder Home Address and Midwinter program. Badges are not required for admission to ADAA courses, but are required for admission to the exhibit floor. City/State/Zip E–mail (required) On–Site Registration E=mail needed to send confirmation.On–site registration for courses will take place outside the room in which courses are being presented and will be handled on a first– Daytime Phone: come, first–served basis if space is available. A charge of $10 will be added to the course fee for ADAA Members, E-Members and Payment made by: Non–members. Those registering on–site for ADAA courses will also have to register at the CDS registration desk if they wish to obtain a � Check � MasterCard � Money Order � Visabadge and badge holder, required for admission to the exhibit floor, and to obtain a general program. There is no CDS registration fee for Charge Card Account Informationmembers of the Illinois Dental Assistants Association. Illinois ADAA __ __ __ __–__ __ __ __–__ __ __ __–__ __ __ __members, be sure to bring your membership card for free CDS reg-istration on–site. All other assistants, even if members of other ADAA Expires __ __ / __ __ (month/year)state components, must pay a registration fee to CDS for badge and badge holder. Cardholder Name Cardholder Address Continuing Education CreditThe courses offered by ADAA at this meeting are approved for CE Cardholder Signature Credit with the Dental Assisting National Board and most state agen-cies requiring dental assisting continuing education. (Check with your state board if you have any questions.) Total Amount Enclosed: $ IL residents must add 10% sales tax.ADAA is an AGD–Approved National Sponsor This form, to be returned to ADAA, registers you for ADAA educa-FAGD/MAGD Credit 04/10/1992 to 05/31/2015 Provider ID# 217389 tion only. You must register with CDS by mail or on–site to receive a badge and a program and access to the exhibit hall. You will be notified if the class is full. NO REFUNDS. Seat not guaranteed 10 minutes after start of program.CDS-2012