Not a member? Go to www.adha.org to become one today!
Registration Form
GRDHA CE
Use this form to register for any or all classes. Complete and return to:
TIFFANY BOYD
6619 Gateline Dr
Richmond, VA 23234
You may register for individual courses up until 1 week prior to the event. Register for one or all courses before September 26th and receive a one-time early bird discount of
$5.00 off your registration fee!
Seating is limited, so please register early!
Make Checks Payable to GRDHA
Questions? Tiffany may be reached at 804-986-7342
Name:_________________________________________________________________
Address:________________________________________________________________
Phone #:________________ E-mail Address:__________________________________
Check one:
Hygienists:
Member _____ ADHA ID #: ______________________
Potential Member _____
Student _____
Others Attending:
Name/Position: ______________________________________________
______________________________________________
Class: Amount paid:
Cosmetic Surgery
Friday, October 9, 2009 8:00AM-12:00PM __________
Ultradent
Thursday, November 12, 2009 6:30PM-8:30PM __________
Ergonomics/Nutrition
Thursday February 4, 2010 6:30PM-8:30PM __________
Periodontal Disease
Tuesday March 9, 2010 6:30PM-8:30PM __________
Total: __________
Early Bird Discount ($5.00) (Prior to September 26th) __________
Total Registration Fee: __________
Cancellation policy: A 48 hour notice is required for refund.
Sun, Jan 10, 2010
Component 02, Component News