Connect4Success Registration – June 19-21, 2025 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 a 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 special meals only. If your guest is attending CE courses, they must complete a separate registration form.


Bringing children?  YES  NO Name


Name Name


Please Provide Child Name/Age Age


Age Age


Where are you staying?  Margaritaville Lake Resort  Other


SPECIAL EVENTS & MEALS These special events are free, but please indicate if you/guest/children will be attending to assist the MDA in planning.


SALT & LIME WELCOME RECEPTION Thursday 5:30pm-7:30pm, Families Welcome


 YES  NO # Attending


NEW DENTIST HANGOUT Thursday Evening 7:30pm-8:30pm, Exclusive to dentists who graduated 10 years ago or fewer (adult guest/spouse welcome) Dentist Attending  YES  NO Guest Attending  YES  NO


YOGA SESSION  YES  NO Friday Morning 7:15am-8am, Adult Guest Welcome


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


# Attending # Attending


AWARDS DINNER & SATURDAY NIGHT LUAU Members may attend the awards reception and dinner only at no cost. Party registration includes two drink tickets per registrant.


Reception & Dinner (Members) Reception & Dinner (All Others)


Reception, Dinner & Party (Members) Reception, Dinner & Party (All Others) Party Only (Any Attendee)


$0


$45 $25 $70 $25


Saturday Evening Childcare (Per Child) $50


# Attending # Attending # Attending # Attending # Attending # Attending


# Attending Please Provide Guest Name


CE COURSES (PLEASE SELECT ONE EACH DAY) New Dentist Recommended | Dental Team Track | Dental Hygiene Track


Friday Morning – 9am to 12pm


 Cutting Edge Techniques and Materials to Maximize Success of Posterior Composite Resin Restorations (Geissberger)


State Zip


 Pediatric Oral Pathology: From Soft Tissue Lesions to Canker Sores (Yepes)  Forward Focused Practice (Webber)  The RDH Toolkit: A Modern Approach to Prevention (Auger)


Friday Lunch Bunch CE – 12pm to 1pm FREE, BUT MUST REGISTER  Kontact Implants: A New Spin on Implantology (Biotech Dental USA)


Friday Afternoon – 1:30pm to 4:30pm


 Why Are My Teeth Getting So Short? Managing, Altering and Improving Vertical Dimension (Geissberger)


 Update in Dental Traumatology: Where are We in 2024 (Yepes)


 Five Energy & Productivity Vampires in Your Practice and How to Overcome Them (Webber)


 Progressive Periodontal Therapy (Auger) Saturday Morning – 9am to 12pm


 Hand-On Veneer Workshop: The Essence of Smile Design (Geissberger) Additional $75 fee, please mark below. Course limited to 35 registrants.


 New Frontiers in Dental Materials to Use in the Pediatric Patient (Yepes)  The High Performing Team’s Playbook (Webber)


REGISTRATION FEES Includes all courses, meals and most events.


 Member $349


 New Dentist Member $209  Retired Dentist Member $249


GRAND TOTAL Please Add All Registration Fees + Special Events & Meals


 Non-Member $699


 New Dentist Non-Member $349  Dental Team Member $239


 Veneer Hands-On Course Fee $75  Class of 2025 Grad $99 $


PAYMENT INFO  Check OR Credit  VISA  MASTERCARD  DISCOVER (AMEX NOT ACCEPTED)


Card # Exp Date


Billing Address City


State REFUNDS & CANCELLATIONS


Request for a refund/cancellation must be emailed to Mandy Lewis. A $50 cancellation fee per registration will be charged through June 13, 2025; 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 or EMAIL mandy@modentalmail.org.


CSV Zip


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