Winter C.E. - Walt Disney World® ResortCE

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

Other attendees:

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

C.E. Seminars
Fee Per Person
# Attending

LDA Members
ADA Members
Assoc. Members
Other Staff
Dental Student
Ret. vol. lic.
*Add LATE FEE of
$50 per person after
Feb. 10, 2014

Special Events
Fee Per Person
# Attending
(Must register for brunch by February 26, 2014, even if you are a C.E. registrant and are attending for FREE.)
C.E. Attendees
-No Charge-
Other Adults
(**A child is someone
12 or under.)
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 Winter Lecture Series
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.

After Feb. 10, 2014, refunds will only be granted with approval of the Council on Dental Education. In the event the meeting is cancelled, all registration fees will be refunded, less proportional cost of materials already produced and distributed.

Questions or Comments: