Exit Registration Form SCDL Official 2016 Online Registration Form Question Title Please complete each question of the official online registration form. Use "none" or "N/A" in fields that are not applicable. Question Title 1. Please complete the following: Laboratory/Company Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Fax Email FL Lab License # (if applicable) REGISTRATION CATEGORIES & FEES Member rates apply to SCDL members in good standing, educators, civil service and active military personnel. Name badges are required at all functions. Requests for reasonable accommodations, as provided by the ADA, must be received in writing in the SCDL office by 3/2/16. FULL REGISTRATION: SCDL Members, Educators, Civil Servants, Active Military: $59 Non-Members: $228* Includes Fri/Sat Technology Summitpresentations; Fri/Sat Leadership Summit presentations (max. two per lab); Friday evening Cocktail Reception; Sat lunch; exhibits; table clinics; breaks. Eligible for door prizes. *Non-member registration includes 2016 SCDL Laboratory Membership, which entitles all additional registrants from this lab to register at member rates. SCDL Member BOGO Special! For every Full Registration, you may register an additional person from your SCDL member laboratory at half price ($29.50). Offer expires February 29, 2016. LEADERSHIP SUMMIT The Leadership Summit is limited to two (2) participants per laboratory. Please note that Leadership Summit content is appropriate for laboratory owners/managers. EXHIBIT HALL ONLY PASS: SCDL Members, Educators, Civil Servants, Active Military: FREE Non-Members: FREE Includes exhibits, table clinics. Eligible for door prizes. Does not include CE credits, seminars, meals, or breaks.No CE credits available with Exhibit Hall Only Pass. OPTIONS & EXTRAS: Saturday Lunch: $30 per ticket Saturday, March 19; 11:15 AM -- 12:00 PM OR 12:00 PM -- 12:45 PM. Lunch included with Full Registration. Must indicate time below. Question Title 2. FIRST ATTENDEE REGISTRATION: Please complete all requested information. Full Name Nickname CDT/RG/DDS/DMD/Other CDT # Food Allergies Question Title 3. Please select the answer that best describes your membership. SCDL Member/Educator/Civil Servant/Active Military Non-Member/Exhibitor Question Title 4. Registration Type Full Registration Exhibit Hall Only Pass (No CE Credits) Question Title 5. Please check all that apply. Lab Owner Manager Technician Dentist Spouse/Guest Student Other (please specify) Question Title 6. Will you be attending the Leadership Summit? The Leadership Summit is limited to two (2) participants per laboratory. Please note that Leadership Summit content is appropriate for laboratory owners/managers. Yes No Question Title 7. Options & Extras Saturday Lunch: $30(Included with Full Registration.) Question Title 8. Attendee Total: Question Title 9. Do you have additional attendees? Yes No Next