Welcome
2015 SDDA Annual Session Registration
PRE-REGISTRATION DEADLINE: FRIDAY, May 8, 2015

PRACTICE AND OFFICE INFORMATION
 
Fields with red asterisk * have to be filled in.
Remember, you must fill out a form for everyone you want to register.

Practice / Dentist Name 
Mailing Address            
City  *                State *     Zip * (5 Digits)
Day Phone # *    (Please use this format 605-555-5555)
E-mail Address
Registrant Information

First *      Last *

First Name / Nickname For Badge *
Register as *   If "Other" enter description 
Spouse Information
Spouses of ADA member dentists who do not work in the dentist office may register for free. You MUST fill out a second form for them, choosing "Dentist Spouse" from the "Register as" drop down list.
REGISTRATION FEES
 

 

SDDA Member Dentist (prepaid with annual dues)
ADA# please enter without dashes
$0.00
ADA Member Dentist (only for SD Affiliate and ADA out of state members)
ADA# please enter without dashes
$150.00
ADA Life Member Dentist
ADA# please enter without dashes
$0.00
Dental Spouse $ 0.00
Dental Students $ 0.00
Nonmember Dentist $ 450.00
*SDDA Member Allied Staff
  2015 Member # in order to receive this rate.
$ 40.00
*Become SDDA Member Allied Staff ($35 & Annual Session Registration ($40) $75.00
*Nonmember Allied Staff $120.00
*Allied Staff includes dental hygienists, dental assistants & office staff.

          REGISTRATION FEE: 

Schedule, May 14-16, 2015
(Registration fee applies to all CE below, except where indicated)
Day Session Time Attending

Wednesday pm Ms. Gill & Mr. Atkins "Meeting HIPAA Requirements" 3:00 pm - 5:00 pm

Thursday am KEYNOTE ADDRESS: Ms. Grayzel "Tongue Tied" 8:00 am - 9:00 am
Thursday am CPR Renewal (Maximum of 8 people) $50 9:00 am - 12:00 pm
Thursday am Ms. Grayzel "Ignite the Power in Story" 9:30 am - 11:30 am
Thursday am Ms. Dewhirst "Annual OSHA Update" 9:30 am - 12:00 pm
Thursday am Dr. Shafie "Implant Overdenture" 9:30 am - 12:00 pm

Thursday pm CPR Renewal (Maximum of 8 people) $50 1:00 pm - 4:00 pm
Thursday pm Dr. Shafie "Implant Placement" 1:00 pm - 3:30 pm
Thursday pm Dr. Glassman "Treating People With Disabilities" 1:00 pm - 5:00 pm
Thursday pm Ms. Dewhirst "Infection Control" 1:30 pm - 4:00 pm

Friday am Ms. Dewhirst "Lesions & Lifestyles" 8:00 am - 11:30 am
Friday am Dr. Willhite "The Ultimate Esthetics Course" 8:00 am - 12:00 pm

Friday pm Ms. Dewhirst "Ergonomics" 1:00 pm - 3:30 pm
Friday pm Dr. Willhite, cont. 1:00 pm - 3:30 pm

Saturday am Mr. Mark Jurkovich "Electronic Dental Records" 8:00 am - 11:30 am
Saturday am Dr. Graeber "Diode Lasers" 8:00 am - 11:30 am
Saturday am Drs. Vezeau & Dean "Anesthesia & Sedation" $500 8:00 am - 5:00 pm
Saturday am "Radiology Review 2015" $35 (includes lunch)
2 hours radiology credit
11:30 am - 1:30 pm

Saturday pm Dr. Graeber, cont. 1:00 pm - 4:00 pm

 

SOCIAL EVENTS & FEES
 

Please indicate number attending, including FREE events


Day

Event

Time

# Attending

Amount
Thursday Exhibit Hall Lunch 11:30 am @ $ 10.00
Thursday New Dentist Lunch
(NOTE:  Free for dentists who have practiced for five or less years. )
11:30 am
Please enter the number for paid or free lunches
@ $ 25.00

@ $   0.00


Thursday CPR Review 9:00 am or 1:00 pm @ $ 50.00
Thursday Exhibitor's Reception 3:00 pm @ $   0.00
Friday ICD Members' Breakfast 7:00 am @ $ 15.00
Friday Paint & Brunch Event 9:45 am @ $ 35.00
Friday Exhibit Hall Lunch 11:30 am @ $ 10.00
Friday Mixer 6:30 pm @ $ 30.00
*Buy a table for 10 people @$270.00
Saturday Anesthesia & Sedation 8:00 am @$500.00
Saturday Awards Lunch 11:30 am @ $ 25.00
Saturday SDDAA Radiology Review 11:30 am @ $ 35.00
SOCIAL EVENTS & FEES TOTAL:     
TOTAL SOCIAL EVENT AND REGISTRATION FEES:     
If you want to print this application for your records, use the Print command under the File menu. You should print it before you hit the Submit Registration button.
Remember, you must fill out a form for everyone you want to register.
 

Once you hit the submit button it will take a moment to process before continuing to the confirmation page.
Please click the Submit button only once.

Allied Membership Application
THIS SECTION ONLY NEEDS TO BE FILLED OUT IF YOU ARE JOINING AS AN SDDA ALLIED MEMBER WITH THIS REGISTRATION.
Date of Birth * (Please enter date in mm/dd/yyyy format)
 
Member Type *

Mailing Address *

City State Zip     (5 Digits)
  
Preferred Phone # *

Choose your Primary mailing address *

Dental Education Program (Optional)
School   City   State
Date of Graduation
Date of Licensure in South Dakota
South Dakota License #
Licensed in the following state(s)

Personal (Optional)
Marital Status    Spouse's Name (include last name if different)
Are you interested in volunteering for community presentations, oral screenings, and health fairs?
(Administrative Fields For Office use -v.02242015)
ADA/Allied Number:    Registration Type