The Mid-Atlantic P.A.N.D.A. Train the Trainer: Registration Form 2019
DEADLINE TO REGISTER - NOVEMBER 1, 2O19
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Email *
Friday, November 15, 2019 | 8:30am-4:00pm                                                                          
Amherst House in Kings Contrivance Village Center
Requirements to be a presenter of the Mid-Atlantic Prevent Abuse and Neglect through Dental Awareness (P.A.N.D.A.) training:
*Commitment to provide at least one training in two years
*Attend the training and retraining that are required to be a trainer and be registered with the MSBDE
*Agree to follow the Seminar Request protocol when corresponding with organizations
*Report all trainings to the Mid-Atlantic P.A.N.D.A. Board via midatlanticpanda@gmail.com
Disclosures:
*The training manual and flash drive are the property of Mid-Atlantic P.A.N.D.A.  At the time of the retraining you are required to return the old flash drive and manual to receive your new flash drive and manual.
*Trainers are registered with the Maryland State Board of Dental Examiners.  
*Volunteer trainers donate their time.
*Attendees for the live presentations are to contribute per the signed Letter of Agreement to help defray the organization's costs.
*To avoid conflict of interest issues, trainer candidates are asked to disclose commercial affiliations that may disqualify their participation.

Please register to attend the Train the Trainer on November 15, 2019
First Name *
Last Name *
Credentials *
Address *
Work Phone Number *
In what areas are you available or willing to present? *
If you currently have an organization in mind to which you plan to give a presentation, please include the name of the organization here:
By checking this box I confirm that I understand the requirements of being a Mid-Atlantic P.A.N.D.A. trainer and I agree to disclose any commercial affiliations/conflicts of interest. *
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A copy of your responses will be emailed to the address you provided.
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