2022 AP Westfall Registration

Name *

First Name Last Name

Ortho Graduation Year *

Email *

example@example.com

Phone Number *

Area Code Phone Number

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Name of Spouse or Guest(s) if planning to attend

Meeting Registration

Includes one ticket to Friday, June 3 business lunch and 9 hours of CE credit

Please select one of the following:

Member Registration Guest (parent, spouse, or child of active member) Guest (orthodontist accompanied by a member) Retired Member 2021 UT Houston Graduate Current UT Houston Resident Full time UT faculty

Name of Member Attending With You

Do you plan on attending the Friday business luncheon? *

Yes No

Friday Night Backyard Bash

Join us Friday June 3rd from 6:30-8:30 for a social and casual meal. There will be an open bar, face painting, and baloon artists.

Residents Attending (no charge)

Adults Attending ($25 each)

Children 12 And Under Attending ($25 each)

Ages of Children Attending

Please list any dietary restrictions

Golf Tournament

The tournament will be held Saturday June 4th from 12:30-6:00 and is $225 per golfer. Registration fee includes green fees, cart, and boxed lunch.

How many golfers in your party?

Do you have any pairing requests?

Sunday Family Breakfast and Devotional

Prior to the lecture on Sunday, we will have a family breakfast followed by a brief devotional. Please provide the total number of people (including yourself) who plan on attending the breakfast.

Total Number Attending Breakfast *

Total

Total Registration Fee

USD Your total will be charged via PayPal on the following screen. After completing the payment process you will receive an email receipt and a list of your registration selections.