ALL applications and abstracts must be submitted electronically via the SCADA website. The Creative Clinician Scientist Manual is an all inclusive guide to preparing your poster presentation and is available the Adobe Acrobat PDF format on the SCADA website at www.scadaresearch.org.

Please Note: When inputting number into the form, do not use spaces or dashes.


PRIMARY PRESENTER:

Last Name:	First Name:	M.I.:

Please type your full name as you want printed in the ADA07SanFrancisco Official Program:

All participants must be members of the American Student Dental Association (ASDA).

American Student Dental Association Membership Number:	Birth Date:	Gender:
		Male Female
Name of School: Please list the full name of your dental school, no abbreviations.	Month & Year of Graduation:
Student's Mailing Address:	Cell Phone:
Alternate Address During Summer Months (if different from above):
Primary E-Mail Address:

INDICATE JUDGING CATEGORY: (Please see the Student Clinician Research Manual for definitions)


I - Clinical Research / Public Heath II - Basic Science Research
Title of Poster Presentation:

Important: Please include an electronic version (Microsoft Word) of your abstract or summary of your poster presentation (250 words maximum). Please refer to the regulations in the ADA/DENTSPLY Student Clinician Research Manual. Your abstract or summary cannot have the name of your school or any other school displayed.

Click here to submit your abstract.


NAME OF CO-CLINICIAN: (if any)

Last Name:	First Name:	M.I.:

ASSISTANCE: Poster presentations that are developed with little or no assistance are prefered. However, if assistance was received in the development of either the protocol or in the production of any aids used, or if substantial materials were borrowed or purchased, please report below.


TYPE OF ASSISTANCE RECEIVED:


Materials Purchased or Borrowed
Please Specify Items:


NAME(s) & TITLE(s) OF PERSON(s) WHO PROVIDED ASSISTANCE:

Last Name:	First Name:	Title:

Taking into account all the time and effort that went into developing the poster presentation, please estimate the percent of the total effort expended that was provided by those who assisted you:

By checking this box it verifies that I have thoroughly read, understand and agree to abide by the program regulations list on page thirteen of the Creative Clinician Scientist Manual. I hereby release and agree to hold harmless the American Dental Association, DENTSPLY International and the Henry B. Gonzalez Convention Center from any and all liability for damage or loss of my goods and property.