AGD STUDENT CHAPTER

PARTICIPANT REGISTRATION FORM

Academy of General Dentistry (AGD) Student Chapters are an important source of relevant, real-world information for
today’s young dental professionals. Through guided events hosted by local AGD representatives and invited speakers,
attendees can observe the latest dental techniques, receive valuable practice management advice, identify leadership
opportunities within organized dentistry, achieve AGD Fellowship credit hours, and much more.

The AGD requests that all Student Chapter Participants are registered with AGD Headquarters. Please complete the
following section below to register a Student Chapter Participant.

Please print.
Name:
School:
Current Street Address:
City:
State, Zip/Postal Code:
Phone:
Email:
*Permanent Home Street Address:
City:
State, Zip/Postal Code:
*Permanent Email:
Graduation Date:
AGD Membership Join Date:
*Please enter your permanent/parents’ address here. Please do not only enter school address as the AGD would like to
keep in touch with students after graduation.

Student Chapter Participants are not considered AGD Student Members until membership dues are paid in full with AGD
Headquarters. If you have any questions regarding AGD membership, please contact the AGD Membership Services Center
at 888.AGD.DENT (888.243.3368) membership@agd.org, or visit www.agd.org.

I hereby certify that all of the above information is correct. By signing and submitting this Student Chapter Participant
application, I agree that I will adhere to all AGD Student Chapter policies.

Signature Date