Connect4Success Registration: June 25–27, 2026 REGISTRANT INFORMATION


PRINT CLEARLY FOR ACCURACY. One registration/person (except Guest/Child, see below). You may provide payment details on one form only if submitting multiple registrations for a group. Retain copy for your records.


Name Primary Phone


Offi ce Address City


Primary Email Emergency Contact Name


ADA # State Zip Phone


Professional Role  Dentist  Dental Student  Dental Hygienist  Dental Assistant  Offi ce Manager  Front Desk/Receptionist  Insurance/Billing  Dental Lab Tech  Other


GUESTS & CHILDREN Bringing a guest?  YES  NO Name


You may register a guest on this same form if participating in free events and/or purchasing special meals only. If attending CE, a guest must complete a separate registration form.


Bringing children?  YES  NO Child Name


Child Name Child Name


Where are you staying?  Margaritaville Lake Resort  Other


SPECIAL EVENTS & MEALS (FREE – RSVP REQUIRED) SALT & LIME WELCOME RECEPTION, Thursday 5:30–7:30pm, Families Welcome Attending?  YES  NO


# Attending


NEW DENTIST HANGOUT, Thursday 6:30–8pm Dentist Attending?  YES  NO


Guest Attending?  YES  NO Exclusive to dentists who graduated 10 years ago or fewer (adult guest/spouse welcome).


YOGA SESSION, Friday 7:15–8am, Adult Guest Welcome Attending?  YES  NO


# Attending


UMKC ALUMNI RECEPTION, Friday 6–7:30pm, Exclusive to UMKC Alumni & Adult Guest Attending?  YES  NO


# Attending


GUEST MEAL ONLY OPTION Includes 2 Receptions (w/Drink Tickets), 2 Breakfasts, 1 Lunch & All Breaks  Adult Guest


$65  Child Guest Age 9-18 (8FREE) $30


# Attending # Attending


AWARDS DINNER & SATURDAY NIGHT LUAU Party registration includes two drink tickets per registrant. Reception & Dinner (Members)


$0


Reception & Dinner (All Other Adults) Reception & Dinner (Child Age 9 & Older)


$55 $20


Reception & Dinner (Child Age 8 & Younger) $0 Reception, Dinner & Party (Members)


Party Only (Any Attendee) Saturday Evening Childcare (Per Child) $35


Reception, Dinner & Party (All Other Adults) $80 $35 $50


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


Card # Exp Date


Billing Address City


State CSV Zip


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


REFUNDS & CANCELLATIONS Request for a refund/cancellation must be emailed to Riley Bernskoetter. A $50 cancellation fee per registration will be charged through June 17, 2026; 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, Jeff erson City 65109 or EMAIL riley@modentalmail.org.


ROOM RESERVATIONS Deadline to reserve at Margaritaville Lake Resort is Wednesday, May 20.


CONNECT4CASH Purchase your MDA Foundation raffl e tickets to win cash and prices.


Age Age Age


CE COURSES (SELECT ONE PER DAY) New Dentist Committee Suggested Track | Dental Team Track | Dental Hygiene Track


Friday Morning – 9am to 12pm


 Part I: Actions & Algorithms for Medical Emergencies: Multiple Actions to Prevent a Medical Crisis in Your Office (Pompa)


 Building the Ultimate Practice – Proven Systems to Increase Practice Production Every Year (Levin)


 Take This Job & Love It (Hyman)  Creating Long-Lasting Patient Outcomes: No Scaler Required (Strange)


Friday Afternoon – 1:30pm to 4:30pm


 Part II: Actions & Algorithms for Medical Emergencies: Updated Medications & the Routes of Administration Used When Treating a Medical Emergency (Pompa)


 Mastering Case Presentation – Getting to “Yes”! (Levin)  A 360 Slam Dunk for Successful Teams (Hyman)  Prevention: The Hollow Leg of Dentistry (Strange)


Saturday Morning – 9am to 12pm  To Pull or Not to Pull (Pompa)  The 5-Star Customer Service Practice (Levin)  A Day in the Life of High-Performing Dental Teams (Hyman)


REGISTRATION FEES INCLUDES ALL COURSES, MEALS & MOST EVENTS  Member Dentist $349


 Non-Member Dentist $699


 Recent Grad Member Dentist $209  Recent Grad Non-Member Dentist $349  Retired Member Dentist $249  Dental Team Member $239  Class of 2026 Grad $99


 Saturday CE Only $99


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


$


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