ONLINE APPLICATION FORM FOR THE GDHA RECOGNITION AWARD
(To complete electronically)
This application is automatically emailed to the committee chair
Application to complete and mail or email (if preferred)

Note: Multiply points times number of incidents

Instructions: Use TAB key to go to next field. Do NOT press the Enter key or form will be submitted incomplete.

Applicant’s Name:

Address:

Phone #

Component: (Click arrow to view choices)

ADHA Member #

Level Applied For:

Please lists points in the blank next to each item. At the end of this form, please cite year, reference, title, committee, etc., as applicable for verification purposes.

A) ATTENDANCE

Dental Hygienists’ Day at the Capital (3 points)

GDHA Workshop or Conference (3 points)

GDHA Annual Session (4 points)

ADHA Special Workshops or Conferences (5 points)

ADHA Annual Session (5 points)

B) ARTICLES (Publications, magazines, newspapers)

Article in Local/Component publication (3 points)

Article in State publication (4 points)

Article in National publication (5 points)

C) PRESENTATIONS

Presentation during NCDHM (3 points)

Presentation to Dental Hygiene Students (3 points)

Presentation to Component or Study club 3 points

Presentation at GDHA Annual Session/Confer/Workshop (4 points)

Presentation at ADHA Annual Session/Confer/Workshop (5 points)

D) TABLE CLINICS

Participation in GDHA table clinic, poster session, etc. (3 points)

Winner of GDHA table clinic, poster session, etc. (4 points)

Judge of GDHA table clinic, poster session, etc. (5 points)

E) NETWORKING

Official representation of GDHA at a function hosted by other than GDHA (Not ADHA Annual Session) 3 points

GDHA Hinman booth worker (3 points)

Contact with legislators on GDHA issues (3 points)

Advisory Board Committee Member or Chair (4 points)

Lobby at Capital for GDHA issues 5 points

Presentation as representation of GDHA at function hosted by other than GDHA (5 points)

F) LEADERSHIP

COMPONENT:

Committee Member (4 points)

Committee Chair (5 points)

Officer/Trustee (15 points)

President (18 points)

STATE:

GDHA Committee Member (7 points)

GDHA Council Chair (15 points)

GDHA Officer/Trustee (15 points)

GDHA President ORCHID

GDHA Award (15 points)

NATIONAL:

ADHA Delegate (7 points)

ADHA Alternate Delegate (5 points)

ADHA Committee Member/Liaison/Council (20 points)

ADHA Officer/Trustee 30 points

ADHA Award Winner (20 points)

TOTAL POINTS

Verification Information:

Please lists points in the blank next to each item. In the large space above, please cite year, reference, title, committee, etc., as applicable for verification purposes.