*First Name:
*Last Name:
*Phone Number:

Other attendees:

(List ALL names for badges, including spouse, guests and children attending the shrimp boil.)

C.E. Seminars
Fee Per Person
# Attending

LDA Members
ADA Members
Assoc. Members
Other Staff
Dental Student
Ret. vol. lic.
*Add LATE FEE of $35
per person after July 9th

Special Events
Fee Per Person
# Attending
Beachside Boil
FREE for seminar
registrants only if
you reserve a place
by July 22
C.E. Attendees
-No Charge-
Beachside Boil
AFTER July 22
C.E. Attendees
Other Adults
(After July 22

Kid's Boil Menu
(Under 12 Only)
(After July 22

Kid's Chicken Menu
(Under 12 Only)
(After July 16
Golf Information
Check the box to the right to allow the LDA permission to share your contact info with any other golfers interested in organizing a round of golf. Info and rates on courses can be found on the LDA website at ww.ladental.org.
Non-refundable credit card convenience fee ($15)
Total amount of fees due to the LDA =
(Please enter your total)

I will pay by: Check or Credit Card

If paying by check, please mail to:
LDA Summer Education Conference
P.O. Box 261173
Baton Rouge, LA 70826-1173

If paying by credit card,
please enter the information below:

Visa/Master Card Number:
Expiration Date:
Name as it appears on card:
3 digit security code on back of card:

NOTE: There is a $15 non-refundable convenience fee for each credit card transaction.

Please list names of ALL attendees for badges because badges are required at all events. Paid registration is required for all dental team members attending education seminars. No C.E. fee necessary for spouses, children and guests, unless they are also dental team members and are attending courses.

All refunds after July 16, 2014, for any reason, will only be granted with approval of the program committee. In the event the meeting is canceled, all registration fees will be refunded less approximate costs of materials already produced and distributed.

Questions or Comments: