Mid-Atlantic P.A.N.D.A. Seminar Request Form

Mid-Atlantic P.A.N.D.A. Seminar Request Form

Please note your seminar will be confirmed when all of the following information is received and approved by your Mid-Atlantic P.A.N.D.A. Trainer.
Name of Organization *
Organization's Address *
Seminar Date *

Month Day Year
Date
Seminar Start Time *

Hour Minutes

AM/PM Option
Seminar End Time *

Hour Minutes

AM/PM Option
Will this training be virtual or in-person? *

Virtual In-person
Will this training be held at your organiztion? *

Yes No
{nameOf} will be responsible for providing a video-conferencing platform.
Location *
Anticipated Number of Participants *
Contact Person *

First Name Last Name
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Have you already identified a trainer? *

Yes No
Name of Trainer *
Would you like to use Mid-Atlantic P.A.N.D.A's CE certificate? *

Yes No

Letter of Agreement
Letter of Agreement between Mid-Atlantic P.A.N.D.A. (M.A.P) and {nameOf}.

M.A.P. is certified by AGD and MSBDE for 2 Continuing Education Credits

Terms, Conditions and Financial Obligations

{nameOf} agrees to provide the following:

Facility space:
- The use of Conference room and audio-visual equipment, including a laptop with USB port and projector.
Payment:

A goal of Mid-Atlantic P.A.N.D.A. is to provide continuing education regarding abuse and neglect to the dental health community. For our live presentations, our volunteer trainers donate their time and we ask seminar attendees to help support our administrative costs.

This cost is $20/dentist and $15/non-dentist (hygienist, dental assistant, front desk staff, etc).

{nameOf} will provid M.A.P. a copy of the sign-in sheet to verify the number of attendees.

Cancellation Clause:
- If M.A.P. cancels the event, {nameOf} will be notified immediately and M.A.P. will attempt to reschedule the course.
I acknowledge I have reviewed the cost structure and agree to remit payment to Mid-Atlantic P.A.N.D.A. in pursuance of this cost structure. *

I agree
Signature

Clear
Should be Empty:

Letter of Agreement