CAPITAL SYMPOSIUMS Registration Form for October 7, 2010

Please include your full name and telephone number on the check. If you are a member of DCDHA, also include an email address.

*PLEASE PRINT*

Check all that apply: _____ ADHA member          _____ Non-Member             _____ SADAH member             _____Non-SADHA member

NAME:______________________________________  DH License #or ADHA#_____________

ADDRESS:_____________________________________________________________________

CITY, ST, ZIP:__________________________________________________________________

Phone #____________________________________(H)_______________________________(W)

E-mail Address:__________________________________________________________________

  Make checks payable to:  “DCDHA”

  Mail to:   Lisa Moore
                 13710 Urbana Lane
                 Bowie, MD 20720-5402
                 (301) 805-6834

QUESTIONS?  
 

DC Dental Hygienists Association
President
Patricia Kotz Shand, RDH
kwpat@cox.net
President Elect
Yolanda Josey Baker, RDH, MPH
jo_bake@verizon.net
www.dcdh.org