Student Chair Form

We invite D3 and D4 dental students

You will receive a $200 honorarium, breakfast, lunch and CE credit for serving the whole day. You must be registered for the Midwinter Meeting.

Prefix

Dr.

Mr.

Ms.

First Name

Last Name

Address 1

Address 2

City

State

Zip

Cell Phone Number

Personal Email Address

School Email Address

Class

D-3

D-4

DMD-AS3

DMD-AS4

Other...

Dental School

UIC-COD

MWU CDM-IL

SIU-SDM

Other...

Service Dates - Please check all the available days you are available to serve. You will be assigned to serve on one of those days.

Thursday, Feb. 22, 2024

Friday, Feb. 23, 2024

Saturday, Feb. 24, 2024

I agree to provide a personal signature in order to allow CDS to process my per diem check

I agree