School Alumni Chapters


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  • Registration Form

    First Name*
    Last Name*
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    Phone (Home)()-- ext.
    Phone (Business)()-- ext.
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    Class of*

    Friday, April 24, 2015

    Travis Taylor Fundraiser Golf Tournament - Deerfield Golf Course
    7:30 a.m. Breakfast with Sponsors
    8:30 a.m. Six Man Scramble Tournament
    12:30 p.m. Lunch and Awards
      $75 per person if registered by April 17.
    • After that date, onsite registration - $85 per person.
    • Fee includes breakfast, cart/green fees, range balls, and lunch.
    Team member preference (six man teams - participant may request up to 5 teammates)
    • Teammate 1:
    • Teammate 2:
    • Teammate 3:
    • Teammate 4:
    • Teammate 5:

    • First Name:
    • Last Name:
    Dental Alumni and Friends Cocktail Reception/Dinner - Old Capitol Inn
    Honoring the Classes of 1980, 1985, 1990, 1995, 2000, 2005, 2010
    Dental Alumnus of the Year Recognition
    6:30 p.m. Cocktail Reception
    7:15 p.m. Dinner Seating (3 course gourmet dinner)
    9:00 p.m. Honored Class Pictures
      $95 per person if registered by April 17.
    • After that date, onsite registration - $100 per person.

    • First Name:
    • Last Name:
    Please list the total number of people (including yourself) who will attend the golf tournament: 
    Please list the total number of people (including yourself) who will attend the reception/dinner: 
    Please list any accessibility resources (e.g. sign-language interpreters, wheelchair access, dietary, etc.) you or your guest may require during this event: 

    Credit Card Information

    Total amount to be billed:

    Please pay with Visa or Mastercard only.
    Card Holder Name*
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    Credit Card CVV Number*
    Located on the back of the card
       CVV