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. All courses at the GDA meeting are open at no additional charge to registered attendees.
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.”
125.00 155.00 45.00 30.00
105.00 135.00 25.00 10.00
Children’s Activities / Meal Bike Through Time Tour Fernandina Trolley Tour / Lunch Friday Fun Night (13+) Friday Fun Night (12 / Under)
________ ________ ________ ________ ________ ________
________ ________ ________ ________ ________ _______
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:
Total: _________________________________
Ck #: _________________________________
Date Charged: _________________________
CK _________ VI_________ MC __________
GDA OFFICE Date Received: _________________________
* CORPS is GDA Associate Membership. CORPS annual dues are $15 per staff member. If you pay 2012 CORPS dues, CORPS staff members attend this meeting free! Contact the GDA for details. Call Patrice Williams at (800) 432-4357 or email williams@gadental.org. View a CORPS membership form at www.gadental.org.
# If you and your spouse are both current GDA member dentists, you may both register for this one special rate.
TOTAL REGISTRATION: __________
50.00
25.00
185.00 75.00 120.00 65.00
130.00 50.00 99.00 45.00
Golf Tournament Tennis Tournament President’s Dinner Dance (13+) Children’s Dinner / Activities
50.00
30.00 Children’s Breakfast / Activities
TOTAL TICKETS:
50.00
30.00 Awards / Installation Breakfast
SUNDAY JULY 22
160.00
140.00
Cumberland Island Hike
50.00
28.00
Alliance Breakfast
210.00
195.00
175.00
Deep Sea Fishing
196.00
195.00
175.00
Backwater Fishing
SALT Cooking Class
38.00
18.00
5K Beach Fun Run
SATURDAY JULY 21
50.00
30.00
Kickoff Breakfast
________
________
Out-of-State ADA Member 500.00 900.00
125.00
50.00
30.00
FRIDAY JULY 20
________
________
250.00 350.00
GDA Dentists—Married#
________
105.00
85.00
Fort Clinch Tour
________
195.00 300.00
GDA Member Dentist
145.00
125.00
Kayaking (Ages 7-12)
Total Due
165.00
145.00
On / After 7-03-12
Kayaking Tour (13+)
THURSDAY JULY 19
On / Before 7-02-12
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[Name(s): ___________________________________]
[Name(s): ___________________________________]
[# Entree(s): _____ Beef / ______ Fish / ______ Veg
[Name(s): ___________________________________]
[Name(s): ___________________________________]
[Name(s): ___________________________________]
[Name(s): ___________________________________]
[Name(s): ___________________________________]
[Name(s): ___________________________________]
[Name(s) / Shirt Size _________________________ ]
[Name(s): ___________________________________]
[Name(s): ___________________________________]
[Name(s): ___________________________________]
[Name(s): ___________________________________]
[Name(s): ___________________________________]
[Name(s): ___________________________________]
Event Details / PLEASE PROVIDE PARTICIPANT NAMES and Other Information as Requested
_______________ + REGISTRATION = ______________________
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Total Due
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Number Tickets
SELECT YOUR EVENT TICKETS: See Guide or Web Site for Minimums / Maximums / Early Deadlines
# of Persons
On / On / Before After 7-02-12 7-03-12
Dentist / Staff Category
Check if you joined the GDA for the first time in 2011 or 2012 and have never before attended a GDA Annual Meeting. Your registration could be FREE! Contact the GDA office for details. Call Pam Yungk at (800) 432-4357 or email yungk@gadental.org.
SELECT REGISTRATION CATEGORY
2012 GDA Annual Meeting • July 19 - 22 • The Ritz-Carlton Amelia Island, Florida