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FUTURE OF DENTAL HYGIENE COMMITMENT FORM

GDHA is setting up a separate legislative communication network for hygienists to receive legislative information.
(Fill out and submit only if you want to receive legislative information)

Click HERE to see information about completing electronic forms.
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As a concerned Registered Dental Hygienist, I make the following commitment to be legislatively active for the profession of dental hygiene. (check all that apply):

  1. I want to receive legislative information. Yes No
  2. I will be a member of ADHA, GDHA and component. YesNo   Need application.
  3. I will contact my Representative and Senator by phone, fax, email, letter, visit.
  4. I will promptly contact my legislators when called upon by GDHA.
  5. I will come to the Capital in Atlanta to lobby. I am available on:
    Mon. Tues. Wed. Thur. Fri.
  6. I will contact Committee members of the legislature.
  7. I will provide testimony at hearings.
  8. I will attend hearings in presence only.
  9. I will adjust my work schedule to come to hearings.
  10. I will make a financial contribution to GDHA.
  11. I will call 4 hygienists on the phone tree network and pass message along.
  12. I will be a GDHA primary contact for my legislators.

My House Representative is:
My Senator is:

If you know other Legislators, please list:

My friends and family know:

If you are a member of another association or group that has lobbying forces, please list:

If you know of someone who is a member of any healthcare, public health advocacy group, list:

List any comments or additional information:

Your Name

Address

City, Zip

Phone (H)(W)

Fax (H) (W)

Email

ADHA member Non-member

The information you submit will be automatically e-mailed to Cheryl Haynes.

Information about Completing Electronic Forms:

  1. Place and click your mouse pointer inside the field areas before beginning to type information.
  2. To advance to the next field, use the Tab key on your keyboard or move the mouse pointer to the next field and click.
  3. If you press the Enter key, the form will be submitted, so do NOT press it after a text entry or to try to advance to the next field.
  4. The Submit Information button at the bottom of the form will submit your information and it will be automatically emailed to Cheryl Haynes.
  5. If you click the Reset button, the information you have entered on the form will be cleared without sending the form.

If you have any difficulty completing this form or if you do not see a confirmation message after submitting your form, click the e-mail button to e-mail the webmaster.
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