Connect4Success Registration – June 20-22, 2024 REGISTRANT INFORMATION
Print clearly for accuracy. One registration per person (except Guest/ Child information). You may provide payment details on one form only if submitting multiple registrations for an group. Retain copy for your records.
Name ADA # Office Address City
Phone Email
GUESTS & CHILDREN Bringing a guest? YES NO
Name
You may register your guest on this same form if they are participating in free events and/or purchasing a guest meal only option. If your guest is attending CE courses, they must complete a separate registration form.
Bringing children? YES NO Please Provide Child Name/Age Name
Name Name
Age Age Age
Where are you staying? Margaritaville Lake Resort Other
SPECIAL EVENTS These events are free, but please indicate if you/guest/children will be attending or not to assist the MDA in planning.
SALT & LIME WELCOME RECEPTION Thursday Evening 5:30pm-7:30pm, Families Welcome
YES NO Number Attending
NEW DENTIST HANGOUT Thursday Evening 7:30pm-8:30pm, Adult Guest Welcome Exclusive to dentists (and guest) who graduated 10 years ago or fewer
Registrant Attending YES NO Guest Attending YES NO
YOGA SESSION Friday Morning 7:15am-8am, Adult Guest Welcome Led by Vicki Wilbers, MDA Executive Director
YES NO Number Attending
CONNECT4CASH TICKETS Want to buy tickets for this fabulous Foundation fundraiser? Scan the QR Code or purchase at
MODENTAL.ORG/C4$
REFUNDS & CANCELLATIONS
Request for a refund/cancellation must be emailed to Mandy Lewis. A $50 cancellation fee per registration will be charged through June 16, 2024; no refunds after this date. All onsite registrations are an additional $25 fee. Return completed form by FAX 573-635-0764 MAIL MDA, 3340 American Ave, Jefferson City 65109 EMAIL
mandy@modentalmail.org
Please Provide Guest Name
CE COURSES (PLEASE SELECT) Purple New Dentist Recommended—Orange Dental Team Recommended
Friday Morning – Choose One Overview of Technologies Advancing Digital Workflows (Various Company Representatives)
Diagnosis, Case Selection and Management of Complex Endodontic Cases (Dr. Joseph Bernier)
Dental Insurance for the Team (Teresa Duncan) State Zip
Friday Afternoon – Choose One Lab Perspective of Digital Workflows (Chris May) Endodontic Instrumentation and Obturation (Dr. Joseph Bernier) Nobody Told Me That: Practice Issues We Should Discuss (Teresa Duncan)
Saturday Morning – Choose One Digital Workflow in Motion (Chris May) Endodontic Irrigation and Hands-On Workshop (Dr. Joseph Bernier) Lecture plus hands-on for additional $75 fee. Course limited to 35 registrants; must also attend Friday afternoon course. Fearless Financial & Case Presentations (Teresa Duncan)
Vendor CE – Free to Attend, Limited Space, Must Register Saturday Breakfast Club: HPP Recognizing the Clinical Consequences of Low ALP (Disease and Diagnosis) – Dental Manifestations (Dr. Mark Cannon, Alexion) CE and Breakfast in Private Room
REGISTRATION FEES Includes all courses, meals and most events.
Member $329 New Dentist Member $199 Non-Member $499 New Dentist Non-Member $299
Retired Dentist Member $229 Dental Team Member $229 Bernier Hands-On Course Fee $75 Class of 2024 Grad $99
GUEST MEAL ONLY OPTION Includes 2 Receptions (w/drink tickets), 2 Breakfasts, 1 Lunch and all Breaks.
Adult Guest Child Guest Age 9-18 (8 FREE)
$65 $30
Number Attending Number Attending
GRAND TOTAL Please Add All Registration Fees + Guest Meals $
PAYMENT INFO Check OR CreditVISA MASTERCARD DISCOVER (AMEX NOT ACCEPTED) Card # Exp Date
CSV
Billing Address City
State Zip
ROOM RESERVATIONS Don't forget to reserve your room at Margaritaville before the room block deadline of May 23! Scan the QR Code to reserve online or call 800-826-8272 (state you are with the MDA).
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32
