2012 Chicago Midwinter Meeting ADAA Round Table Learning Pre-Registration Form

1. Lear ning in the Round
PRE–REGISTRATION DEADLINE
Friday, February 17, 2012
ATTENDEES WILL BENEFIT FROM:
• Product samples, education, door prizes, fellowship and fun.
• 3 CEUs to be earned for each session. ADAA is designated as an Approved PACE
Program Provider by the Academy of General Dentistry.
This course has been approved for DANB CDE credit.
Back by Popular Demand!
Featuring New Products & New Manufacturers
Have fun while you learn in this hands-on small group experience.
Share ideas with other dental assistants in your group while you are introduced
to new products and techniques that will benefit your practice.
You will come away energized with new ideas, new colleagues and lots of prod-
uct samples for your office.
Where: McCormick Place Fees:
West Hall, Room 181A $5 Per Session ADAA Members
Members sign up for both sessions for $8!
When: (2 Sessions*):
$10 Per Session for E-Members & Non–
FRIDAY, FEBRUARY 24, 2012
Members
Session 1: 9 AM – Noon
E-Members & Non-Members sign up for
Session 2: 1:30 PM – 4:30 PM
both sessions for $15
*Different topics will be covered
(No refunds)
in each session.
PRE–REGISTRATION is not required but highly recommended. Preregistration begins November 1, 2011.
Seating will be limited. Don’t miss this opportunity!
147th Chicago Midwinter Meeting
Course Moderator:
Jennifer K. Blake, CDA, EFDA, MADAA
Jen Blake has been a member of the dental
team for over 35 years. She has been a clinical
assistant, educator, and is past president of the
American Dental Assistants Association. Currently
she is serving as ADAA Director of Education and
Professional Relations.
see next page for registration information
Visit us at:
www.dentalassistant.org

2. REGISTRATION INFORMATION By February 17, 2012, return this registration to:
Fees: ADAA Members $5 per session
ADAA Midwinter Meeting
Members sign up for both sessions for $8!
35 East Wacker Drive, Suite 1730
Non–ADAA Members $10 per session Chicago IL 60601–2211
E-Members & Non-Members sign up for both Fax: 312–541–1496 — No telephone registration
sessions for $15
(No refunds) Return form with check, money order or credit card information.
We will not bill you. Faxed forms must include credit card informa-
tion.* ADAA members should include a photocopy of their current
American Dental Assistants Association membership card with faxed or mailed registration.
147th Chicago Midwinter Meeting
McCormick Place — West Hall, Room 181A Registration is also available online Nov. 1, 2011 at
www.dentalassistant.org.
Any change in location will be noted in the on-site program and in the
Registration limited — sign up early. You will be notified by e–
registration materials sent to pre–registered attendees.
mail of your registration.
Pre–Registration for ADAA Learning in the Round Learning in the Round – February 24, 2012
Deadline: February 17, 2012
Pre-registration strongly recommended. Courses will be closed once PLEASE PRINT
maximum registration has been achieved. Registration for this course
Status (Circle One)
is separate from CDS and is handled by ADAA only.
ADAA Member E-Member Non-Member
Pre–Registration for CDS Meeting � 2/24 AM session � 2/24 PM session
Both members and non-members who wish to register for the CDS 9:00–Noon 1:30–4:30 PM
Meeting itself, including admission to the Exhibit Floor, should fill out
CDS Meeting Registration forms and submit them with fee (if any) to
CDS as directed on http://www.cds.org/mwm/.
ADAA Membership Number
All of those pre–registered with the CDS will receive badges during
Name
February in the mail. These registrants need only stop by the Chica-
go Dental Society registration desk to pick up a plastic badge holder
Home Address
and Midwinter program. Badges are not required for admission to
ADAA courses, but are required for admission to the exhibit floor. City/State/Zip
E–mail (required)
On–Site Registration E=mail needed to send confirmation.
On–site registration for courses will take place outside the room in
which courses are being presented and will be handled on a first– Daytime Phone:
come, first–served basis if space is available. A charge of $10 will
be added to the course fee for ADAA Members, E-Members and Payment made by:
Non–members. Those registering on–site for ADAA courses will also
have to register at the CDS registration desk if they wish to obtain a
� Check � MasterCard � Money Order � Visa
badge and badge holder, required for admission to the exhibit floor,
and to obtain a general program. There is no CDS registration fee for Charge Card Account Information
members of the Illinois Dental Assistants Association. Illinois ADAA __ __ __ __–__ __ __ __–__ __ __ __–__ __ __ __
members, be sure to bring your membership card for free CDS reg-
istration on–site. All other assistants, even if members of other ADAA Expires __ __ / __ __ (month/year)
state components, must pay a registration fee to CDS for badge and
badge holder. Cardholder Name
Cardholder Address
Continuing Education Credit
The courses offered by ADAA at this meeting are approved for CE
Cardholder Signature
Credit with the Dental Assisting National Board and most state agen-
cies requiring dental assisting continuing education. (Check with your
state board if you have any questions.) Total Amount Enclosed: $
IL residents must add 10% sales tax.
ADAA is an AGD–Approved National Sponsor This form, to be returned to ADAA, registers you for ADAA educa-
FAGD/MAGD Credit 04/10/1992 to 05/31/2015 Provider ID# 217389 tion only. You must register with CDS by mail or on–site to receive
a badge and a program and access to the exhibit hall.
You will be notified if the class is full. NO REFUNDS.
Seat not guaranteed 10 minutes after start of program.
CDS-2012