Canadian Foundation Event Registration

For attendees from the United States

This is an add-on registration to the full registration.

This registration form will process payment to the US Foundation in USD. If you wish to process your payment through the Canadian Foundation in CAD instead, please use this form.

Proceeds from the event will go to Tel Aviv University School of Dental Medicine Oral Pathology Laboratory Project and the Radiology Center at the new Oral Health Center for People with Disabilities at the Hebrew University Hadassah School of Dental Medicine.

$50 is tax-deductible for U.S. registrants from the $150 Canadian Foundation event registration fee.

Prefix

First Name *

Last Name *

Preferred First Name/Nickname

Chapter *

Write "None" if not affiliated with a chapter.

Address *

Address 2

City *

Postal Code/Zip Code *

Country *

State *

Phone

Email *

Will you require Kosher meals?

Yes

No

How many additional guests (not including you)?

Share the names of your guests

Payment Information

Amount

$ USD

Payment Method *

US Foundation PayPal Send Check via Postal Mail

Credit Card Number*

Expiration Date*

/

Card (CVV) Code*

Card Holder Name*

Please donate to offset PayPal fees

Enter your donation amount above. Suggested donation is 3%, or $4.50 per ticket.

Additional Donation to the Foundation

$180

$360

$720

Other

Enter your custom donation amount:

Numbers only, do not enter $ or punctuation

By registering for this event, I accept the Alpha Omega Dental Society Code of Conduct