Hawaiian Dental Seminar Registration Form



Please Note: * denotes mandantory field.

YES! I will be joining you for the 31st Annual Hawaiian Dental Forum. Which week(s) will you be attending? *
Maui - Hyatt Regency Maui Resort and Spa, January 29-February 5, 2011
Kauai - Grand Hyatt Kauai Resort and Spa, February 5-12, 2011
Both Weeks

Doctor Information
Your Name *
Occupation/Specialty
Mailing Address *
City *
State/Province *
Zip/Postal Code *
Country *
Office Telephone *
Home Telephone *
Alternate Telephone
Email Address *
Spouse Name (if attending)

Attending Staff

Registration Fees Seminar only Registration Fee Per Person IF STAYING at Seminar Meeting Hotel(s) AND Booking Travel Through Travel Leaders (formally Chippewa Valley Travel Service)
Doctor One Week Only - $730   Both Weeks - $1,195   Not Applicable
Spouse One Week Only - $320   Both Weeks - $555      Not Applicable
Staff (per person) One Week Only - $320   Both Weeks - $555      Not Applicable

Seminar only Registration Fee Per Person IF NOT STAYING at Meeting Hotel(s)
Doctor One Week Only - $1,030   Both Weeks - $1,795   Not Applicable
Spouse One Week Only - $620     Both Weeks - $1,155    Not Applicable
Staff (per person) One Week Only - $620     Both Weeks - $1,155    Not Applicable

NOTE: First staff member attending without an accompanying doctor will be charged the doctor's fee. Multiple dentists from the same office must each pay the doctor fee.

Physicians and other health care providers are welcome to attend and receive a certificate of attendance.

Payment Information Please select a payment option *
I am paying a $25 per person deposit using my credit card through PayPal.*
      You are authorized to bill my credit card the balance on January 4, 2011.
I am paying the full amount using my credit card through PayPal.*
I will call you with my credit card information.
I will be sending a check.
Dental Seminars & Symposia, LLC
405 W Prairie View Road
Chippewa Falls, WI 54729
All registrations are considered pending until a deposit has been secured. Our phone number is 715-723-1662.

*Note about PayPal. For more security and simplicity we are now processing all credit card payments through PayPal. It is a simple procedure and you do not have to have a PayPal account. Just click on the "Pay Now" PayPal button and complete the process after you submit this registration.


Questions/Comments



For travel information contact:
Travel Leaders of Chippewa Falls
31 East Columbia Street
Chippewa Falls, WI 54729
1-800-826-6644 (United States and Canada). Ask for Linda Schmick.
E-Mail:
Web Site: www.travelleaders.com/chippewafallswi/index.htm

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