Registration form for CE's:
 
Snail Mail-Checks Only
Print a copy of the registration form and send it with check payable to VCDHA.  Mail to: Peggy Lee RDH, 132 Mesa Dr. Camarillo, CA 93010.

Click Here for Printable Snail Mail Registration Form

OR
 
E Mail Form with PayPal Payment
There are two steps.  Step 1) Fill out and "Submit" registration form below. Step 2)  Send payment using PayPal. When using PayPal please send money to vcdha805@aol.com and make sure to put "CE payment" in subject line. In the message area put your name to match the registration form.

ONLY USE PAYPAL IF YOU HAVE YOUR OWN PERSONAL PAYPAL ACCOUNT LINKED TO YOUR CHECKING ACCOUNT OR CREDIT CARD.  IF YOU DO NOT HAVE A PAYPAL ACCOUNT, YOU CAN CREATE ONE AT PAYPAL.COM
 
PLEASE DO NOT SEND YOUR CREDIT CARD INFORMATION TO PEGGY LEE OR TO THIS EMAIL ADDRESS.  

IF USING PAYPAL AS YOUR METHOD OF PAYMENT PLEASE CHECK TO MAKE SURE IT WAS A SUCCESSFUL TRANSACTION BECAUSE WE WON'T HAVE A RECORD OF YOUR REGISTRATION WITHOUT PAYMENT.

Additional Options

Contact information:
First name:
Last name:
Email address:
License # and ADHA #
Mailing address:
CE Information
Include: CE Course Title, Name(s) of attending with license number, Member or Non-Member Price, and Method of Payment.
Best way to contact you: