OkMOM 2024 - Lawton
Produced by the Oklahoma Dental Association, Oklahoma Dental Foundation and the Delta Dental of Oklahoma Foundation.
We are so excited to announce OkMOM 2024 is returning to Lawton!
Date
Friday, February 9, 2024 to Saturday, February 10, 2024
About You
* = Required
*
E-mail Address
*
E-mail Address Confirm
*
First Name
*
Last Name
*
City
*
State / Province
Choose...
Other
AB
AK
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DE
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GA
HI
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KS
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Enter Other:
Cell Number
Registration Information
* = Required
*
Please choose which volunteer type best describes you:
Select...
General Volunteer
General Dentist
Endodontist
Oral Surgeon
Orthodontist
Pediatric Dentist
Periodontist
Prosthodontist
Oral Pathologist
Registered Dental Hygienist
Dental Hygiene Student- 1st year
Dental Hygiene Student- 2nd year
Hygiene Assistant
Dental Student- 4th year
Dental Student- 3rd year
Dental Student- 2nd year
Dental Student- 1st year
Dental Assistant
Dental Assisting Student
Physician
Medical Student
Registered Nurse
Certified Nurse Practitioner
Nursing Student
Pharmacist
Pharmacy Tech
Pharmacy Student
Physician Assistant
PA Student
Dental Lab Technician
Dental Supply Rep
Dental Supply Tech
ODA/ODF staff
OKMOM Lead
Visiting from another MOM
National MOM staff
EMT
Health Dept. Volunteer
Delta Dental OK
OUCOD Faculty
*
In which state are you licensed to practice?
*
What is your license number?
If you are licensed in a state other than Oklahoma, you will need to visit www.okmom.org and follow the directions for applying for a temporary license just for OkMOM.
*
Have you volunteered for OKMOM before? (Tulsa 2010, OKC 2011, McAlester 2012, Lawton 2013, Enid 2014, Tulsa 2015, OKC 2016, Woodward 2017, Durant 2018, OKC 2019, Stillwater 2020, Shawnee 2023)
Select...
No
Yes, 1 previous OKMOM event
Yes, 2 previous OKMOM events
Yes, 3 previous OKMOM events
Yes, 4 previous OKMOM events.
Yes, 5 previous OKMOM events.
Yes, 6 previous OKMOM events
Yes, 7 previous OKMOM events
Yes, 8 previous OKMOM events.
Yes, 9 previous OKMOM events.
Yes, 10 previous OKMOM events.
Yes, 11 previous OKMOM events.
Yes, all previous OkMOM events
*
Do you speak a language, other than English, fluently?
No
Yes, Spanish
Yes, Spanish and another langauge
Yes, a language other than Spanish
*
What language(s), other than Spanish or English, do you speak?
*
What size t-shirt do you wear?
S
M
L
XL
2X
3X
4X
5X
6X
*
What state are you visiting us from?
*
What supply company do you represent?
Benco
Burkhart
Patterson
Schein
Other...
*
Will you be at least 18 years old on February 8, 2024?
Yes
No (must be at least 16 years old)
Volunteers under the age of 18 are required to submit a parent/guardian release form. You will need to follow the link in the confirmation email or at
www.okmom.org
to submit the form.
Please use this space to add anything to your registration that we may need to know, such as food allergies. Questions can be submitted to okmom@okda.org
*
If you are practicing in Oklahoma, what town or city do you practice in? (Please list all of your office locations- just the town/city names)
Where
Great Plains Coliseum
920 SW Sheridan Road
Lawton, OK 73505
United States
1 (580) 3571483
You will be able to add additional registrants on your "Thank You for Registering" (Confirmation) page.
