APPLICATION FORM FOR THE GDHA RECOGNITION AWARD
(To print and mail in or fill out and email)

Applicant’s Name____________________________________________________________

Address __________________________________________________________________________

__________________________________________________________________________

Phone # _______________

Component __________________

ADHA Member #: _____________________

Level Applied For __________________

Please lists points in the blank next to each item. On a separate piece of paper, 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:

_____ Component Committee Member (4 points)

_____ Component Committee Chair (5 points)

_____ Component Officer/Trustee (15 points)

_____ Component 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)

_____ Winner ADHA Award (20 points)

TOTAL POINTS ________________

Send to Committee Chair: Debbie Hough