Montana Dental Hygienists’ Association with information dental health care and oral hygiene to keep you smiling!

2011 Annual Session Registration Form
Registrant 1

Name:     * Address:    *
City:   *    State:       *     Zip:  *
Email Address:  *
Home Number: 
Are You an ADHA Member?:      

RDH        Student       Dr.      Aux

*  Required

Registration Fee All 3 Days  2 Days 1 Day
  All Three Days Choose a Day
Thurs   Fri   Sat		 Choose a Day
Thurs   Fri    Sat
  Fee if by 9/23 Fee after 9/23 Fee if by 9/23 Fee after 9/23 Fee by 9/23 Fee after 9/23
ADHA/MDHA Member $170.00  $195.00 $140.00 $165.00 $85.00 $105.00
Non-Member Hygienist $220.00 $245.00 $180.00 $205.00 $120.00 $145.00
DH Student $35.00 $60.00 $25.00 $50.00 $20.00 $45.00
           

Installation Dinner
Friday 7:00pm

 Penne Pasta w/ Chicken $22                 Columbia River Salmon $28
Hosted Events RSVP
No Fee		 Wine and Cheese Auction - Thursday 6:30 pm
Presidential Luncheon - Friday 1:00 pm

Registrant 2

Name:     * Address:    *
City:   *    State:       *     Zip:  *
Email Address:  *
Home Number: 
Are You an ADHA Member?:      

RDH        Student       Dr.      Aux

*  Required

Registration Fee All 3 Days  2 Days 1 Day
  All Three Days Choose a Day
Thurs   Fri   Sat		 Choose a Day
Thurs   Fri    Sat
  Fee if by 9/23 Fee after 9/23 Fee if by 9/23 Fee after 9/23 Fee by 9/23 Fee after 9/23
ADHA/MDHA Member $170.00  $195.00 $140.00 $165.00 $85.00 $105.00
Non-Member Hygienist $220.00 $245.00 $180.00 $205.00 $120.00 $145.00
DH Student $35.00 $60.00 $25.00 $50.00 $20.00 $45.00
           

Installation Dinner
Friday 7:00pm

 Penne Pasta w/ Chicken $22                 Columbia River Salmon $28
Hosted Events RSVP
No Fee		 Wine and Cheese Auction - Thursday 6:30 pm
Presidential Luncheon - Friday 1:00 pm

Registrant 3

Name:     * Address:    *
City:   *    State:       *     Zip:  *
Email Address:  *
Home Number: 
Are You an ADHA Member?:      

RDH        Student       Dr.      Aux

*  Required

Registration Fee All 3 Days  2 Days 1 Day
  All Three Days Choose a Day
Thurs   Fri   Sat		 Choose a Day
Thurs   Fri    Sat
  Fee if by 9/23 Fee after 9/23 Fee if by 9/23 Fee after 9/23 Fee by 9/23 Fee after 9/23
ADHA/MDHA Member $170.00  $195.00 $140.00 $165.00 $85.00 $105.00
Non-Member Hygienist $220.00 $245.00 $180.00 $205.00 $120.00 $145.00
DH Student $35.00 $60.00 $25.00 $50.00 $20.00 $45.00
           

Installation Dinner
Friday 7:00pm

 Penne Pasta w/ Chicken $22                 Columbia River Salmon $28
Hosted Events RSVP
No Fee		 Wine and Cheese Auction - Thursday 6:30 pm
Presidential Luncheon - Friday 1:00 pm

Registrant 4

Name:     * Address:    *
City:   *    State:       *     Zip:  *
Email Address:  *
Home Number: 
Are You an ADHA Member?:      


RDH        Student       Dr.      Aux

*  Required

Registration Fee All 3 Days  2 Days 1 Day
  All Three Days Choose a Day
Thurs   Fri   Sat		 Choose a Day
Thurs   Fri    Sat
  Fee if by 9/23 Fee after 9/23 Fee if by 9/23 Fee after 9/23 Fee by 9/23 Fee after 9/23
ADHA/MDHA Member $170.00  $195.00 $140.00 $165.00 $85.00 $105.00
Non-Member Hygienist $220.00 $245.00 $180.00 $205.00 $120.00 $145.00
DH Student $35.00 $60.00 $25.00 $50.00 $20.00 $45.00
           

Installation Dinner
Friday 7:00pm

 Penne Pasta w/ Chicken $22                 Columbia River Salmon $28
Hosted Events RSVP
No Fee		 Wine and Cheese Auction - Thursday 6:30 pm
Presidential Luncheon - Friday 1:00 pm


Total Due:  *
Please add up your total before clicking the continue button below

A few ways to register.   
Print this page, complete, and mail with payment to: 

Attn: Debbie Porter, RDH
MDHA Annual Session
122 Yellowstone Avenue
Billings, MT  59101  -  406-256-7384 

Make checks payable to MDHA. 

or

Submit this page electronically and pay by credit card via PayPal. 

Cancellation Policy: A $25 administrative fee will be withheld from refunds on requests made after 9/23/11. Requests must be in writing. No refund requests will be accepted after 10/5/11.