Welcome
2014 SDDA Annual Session Registration
PRE-REGISTRATION DEADLINE: FRIDAY, May 2, 2014

PRACTICE AND OFFICE INFORMATION
 
Fields marked with a red asterisk * are requried.  Use the tab key to move from field to field.
Remember, you must fill out a form for everyone you want to register.
Once you start the registration process, you cannot go back to make corrections.
If you do not complete the entire process, you will not be registered for the 2014 Annual Session.

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
  2014 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 15-17, 2014
(Registration fee applies to all CE below, except whre indicated)
Day Session Time Attending

Thursday am KEYNOTE ADDRESS: Mr. Olsen "Integrity" 8:00 am - 9:00 am
Thursday am Mr. Olsen "Understanding Personal Strengths" 9:30 am - 11:30 am
Thursday am Ms. Laudenslager "Bloodborne Pathogens Update" 9:30 am - 12:00 pm

Thursday pm CPR Renewal (Maximum of 20 people) $40 1:00 pm - 4:00 pm
Thursday pm Ms. Arends "HIPPA Review" 1:00 pm - 3:00 pm
Thursday pm Dr. Pitts "Esthetics & Function" 1:00 pm - 4:00 pm

Friday am Dr. Lewis "Embezzlement & Fraud" 8:00 am - 11:00 am
Friday am Dr. Low Dog "Nutrition" 8:00 am - 11:00 am
Friday am Dr. Rohrer "Sores & Lessions" 8:00 am - 11:30 am

Friday pm Dr. Lewis "Embezzlement & Fraud" (repeat) 1:00 pm - 4:00 pm
Friday pm Dr. Low Dog "Life in Balance" 1:00 pm - 4:00 pm
Friday pm Dr. Rohrer "Oral Cancers" 1:00 pm - 4:30 pm

Saturday am Ms. Pesche "Are You Mouthwise?" 8:00 am - 11:00 am
Saturday am Dr. Faiella "Advanced Periodontal Therapy" 8:00 am - 11:00 am
Saturday am Drs. Vezeau & Dean "Anesthesia & Sedation" $500 8:00 am - 5:00 pm
Saturday am SDDAA "Radiology Review 2014" $35 (includes lunch) Dr. Denis Miller, 2 hours radiology credit 11:30 am - 1:30 pm

Saturday pm Dr. Faiella "Immediate Implant Placement" 1:30 pm - 4:30 pm

NOTE: To register for USD Radiology on Thursday contact USD at 605-677-5378.
Pre-registration is required!

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 1:00 pm @ $ 40.00
Thursday Exhibitor's Reception 3:00 pm @ $   0.00
Friday ICD Members' Breakfast 7:00 am @ $ 15.00
Friday Dental Spouse Lunch 10:30 am @ $ 20.00
Friday Exhibit Hall Lunch 11:30 am @ $ 10.00
Friday Mixer 6:30 pm @ $ 20.00
*Buy a table for 10 people @$175.00
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 or two to process
then you will be taken to the confirmation page.
Please only click the Submit button 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 and zip     (5 Digits)
  
Preferred Phone # *

Choose your Primary mailing address *

Dental Education Program (Optional)
School
City and 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.03122014)
ADA/Allied Number:    Registration Type