GDA Annual Meeting Registration Form by Delaine Hall

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2012GDA MEET I NGCHAI RS

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FAMI LY nI GHT:Tropi cal Fi re I s land Extraganza

WHO WI LL TAKE THE DI S TRI CT Crown?

Tropi cal Fi re i s land extravaganza

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2012 GDA Annual Meeting • July 19 - 22 • The Ritz-Carlton Amelia Island, FL MAIL: FAX: WEB:

GDA, 7000 Peachtree Dunwoody Rd NE, Suite 200, Bldg 17, Atlanta, GA 30328. Completed forms to (404) 633-3943 with Visa / MasterCard information. Register at www.gadental.org with Visa / MasterCard information. The GDA will email confirmations to all registrants.

GDA BADGE RIBBONS ___ 25 Year Member ___ 50 Year Member ___ Alliance Member (GDA) ___ Alt. Delegate (GDA House) ___ Board of Trustees (GDA)

REGISTERED DENTISTS (REQUIRED)

___ Committee Chair (GDA)

Dentist Last Name _______________________________________________________________ Dentist First Name / Middle Initial __________________________________________________

___ District Officer (GDA) ___ Delegate (GDA House) ___ GADPAC Donor

Name for Badge _________________________________________________________________

___ Honorable Fellow (GDA)

Spouse / Guest Badge Name ______________________________________________________

___ Life Member (ADA) ___ Meeting Host

ADA #____________________________ GDA District _________________________________ Mail Address ___________________________________________________________________ City / State / Zip ________________________________________________________________ Area Code / Phone ______________________________________________________________ Email _________________________________________________________________________ The GDA will email confirmations to all registrants using this address. Please print clearly.

REGISTERED CHILDREN’S NAMES / AGES

ACCOMMODATIONS This form does not register you for accommodations at The Ritz-Carlton Amelia Island. Visit www.gadental.org for a room form. If you reserve a Ritz-Carlton room, but do not register for the GDA meeting, you will be charged full rack rate.

ADA CERP

Child ____________________________________________________________ Age _______ Child ____________________________________________________________ Age _______ Child ____________________________________________________________ Age _______ Child ____________________________________________________________ Age _______

REGISTERED STAFF NAMES / TITLES (RDH, Office, Etc.)

The GDA is an official American Dental Association Continuing Education Recognition Program provider. Courses at the GDA meeting are open at no additional charge to registrants unless otherwise noted.

CANCELLATIONS / DEADLINES Ticketed events may have minimum / maximum registration numbers, and special dates by which registrations must end. Consult the guide or www.gadental.org for details on your event.

Staff _________________________________________ Title ___________________________ Staff _________________________________________ Title ___________________________ Staff _________________________________________ Title ___________________________ Staff _________________________________________ Title ___________________________

PAYMENT (REQUIRED) Paying By:

_____ Check

_____ VISA

_____ MasterCard

Name on Card __________________________________________________________________________ Card Number___________________________________________________________________________ Expiration Date ____________________________ Security Code REQUIRED ____________________

FREE REGISTRATION If you joined the GDA for the first time in 2011 or 2012, are a 2012 member, and have never before registered for a GDA Annual Meeting, you may be eligible for free meeting registration (accommodations, transportation, and tickets not included). Contact the GDA office for details.

REFUNDS The GDA will issue FULL refunds for WRITTEN cancellations received on or before 7-02-12. The GDA will issue 50% refunds for WRITTEN cancellations received between 7-03-12 and 7-08-12. The GDA will issue NO REFUNDS on or after 7-09-12.

Billing Address _________________________________________________________________________ Billing City / State / Zip __________________________________________________________________

REGISTRATION MATERIALS The GDA will not mail meeting materials. Visit the on-site Registration Desk for all materials.

“All registrants acknowledge having read and agreed to this statement: “This function’s planners claim and assume no liability for the acts of meeting suppliers nor for the safety of any registrant or attendee while in transit to or from the GDA Annual Meeting (GAM), or while attending the GAM or any event that is part of the GAM. Registrants, attendees, and participants in any event during the GAM, including but not limited to those which may require or feature physical activity, assume all risk and liability associated with such activity. Parents of any child attending or participating in any event during the GAM assume all risks and liability associated with such activity. The total amount of GDA liability, if any, shall be limited to an attendance fee refund. Your registration acknowledges acceptance of these provisions above, and by doing so you release the GDA, its employees and staff, and all others involved in the organization of this meeting from any liability in case of injury or accident to yourself, your guests, and/or your children, if any, during the 2012 GAM.”

________ ________ ________ ________ ________ ________ ________

________ ________ ________ ________ ________ ________ _______

Out-of-State ADA Member 500.00 900.00

FREE

950.00 1200.00

100.00 200.00

FREE

25.00

100.00 150.00

Student ADA Member

Non-ADA Member

Active Military Dentist

CORPS * Staff Member

Non-CORPS * Staff

Out of State Staff Member

USE ONLY:

_______ _______

145.00 105.00

125.00 85.00

Fort Clinch Tour

_______ _______

120.00 65.00

99.00 45.00

President’s Dinner Dance (13+) Children’s Dinner / Activities

Children’s Breakfast / Activities

Date Charged: _________________________

Total: _________________________________

Ck #: _________________________________

Awards / Installation Breakfast

50.00

[TOTAL TICKETS:

30.00

[Name(s): ___________________________________] [Name(s): ___________________________________]

_______

[Name(s): ___________________________________] [Name(s): ___________________________________]

_______ _______

[Name(s): ___________________________________] [Name(s): ___________________________________] [# Entree(s): _____ Beef / ______ Fish / ______ Veg

_______ _______ _______

_______

_______ [Name(s): ___________________________________]