Registration Form " Aligning your instrumentation skills and preserving your professional career"



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October Continuing Education Course Registration Form

Aligning your instrumentation skills and preserving your professional career”

(3 CEUs)

Lecture Provided By Lillian Caperila, RDH, BSDH, M.Ed.

Sunday, October 23, 2016, 9:00 AM- 12:30 PM, 8:30 AM REGISTRATION

Centra State Medical Center, Star and Barry Tobias Ambulatory Center

901 WEST MAIN STREET, FREEHOLD, NJ 07728

Bagel Brunch is Included Short Business Meeting Before course

At completion of this lecture, participants will be able to:


Register BEFORE 10/12/2016: ADHA Member - $25, Potential Members- $45

Register AFTER 10/12/2016: ADHA Member - $30, Potential Members- $55

Name:____________________________________________________________________

Are you an ADHA Member: ___Y ____N Member #_______________________________

Address___________________________________________________________________

Phone #__________________________________ Office Name:_____________________

Email Address______________________________________________________________

Print form and mail with check made out to CNJDHA to:

Fran Schneider, RDH

96 Joann Court

Monmouth Junction, NJ 08852-2611

We invite currently enrolled student Dental Hygienists to attend for a nominal fee of $15.



Registration needed by 10/12/2016. Complete form and place school name in office name area.

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