ASDA Predental Chapter Request Form

Question Title

* 1. To be considered for an ASDA predental charter, please complete all fields below. ASDA's Predental Advisory Committee will review all requests twice a year: March 31 and September 30.

Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number: *

Question Title

* 2. University Name:

Question Title

* 3. Do you belong to a predental club at your school?

Yes

No

We do not have a predental club at my school

Question Title

* 4. Predental club name (if applicable):

Question Title

* 5. Estimated number of predentals at your school:

Question Title

* 6. Predental club website or Facebook page (if applicable):

Question Title

* 7. Please select from the following options:

I intend to start a predental chapter as my school's first predental student organization

I intend to start a predental chapter outside of my school's established predental club

I intend to convert my existing predental club into an ASDA predental chapter

Unsure

Question Title

* 8. Why do you wish to form an ASDA predental chapter at your school?

Question Title

* 9. As an ASDA predental chapter you will be required to meet the following: all members of your chapter must be national ASDA members, minimum of 10 chapter members, a chapter constitution and bylaws, a signed affiliation agreement, approval of a faculty member or pre-health advisor and a $50 application fee. Do you anticipate any issues in meeting these requirements?

Yes

No

Question Title

* 10. If yes, which requirement do you anticipate having an issue?

National member requirement for all chapter members

Minimum 10 members

Chapter constitution and bylaws

Signed affiliation agreement

approval of a faculty member or pre-health advisor

$50 application fee

N/A