2025 Pediatric Dentistry Alumni Day

RSVP Information

Sponsor a Resident
Select	Description	Amount

Sponsor a Resident to Attend - $90 (Fully tax deductible)

Sub-Total:
Tax-Deductible:

Donation Option

I would like to contribute an additional gift to support UCLA Pediatric Dentistry with a tax-deductible donation.

I would like to make a fully tax-deductible gift of * Other $ *

Grand Total:

Tax-Deductible:

Contact Information

Personal

Title:

First name:

Middle name:

Last name:

Suffix:

I am making this gift as a proxy for my organization/company, which should be recognized as the legal donor

UCLA graduation year(s):

Contact Information

Street:

U.S. Addresses

City, State, Zip:

Non-U.S. Addresses

Non-U.S. City/County
or Province/Postal Code:

Country:

This address is my:

Home

Business

Home telephone:

Invalid phone number *

Business telephone:

Invalid phone number

E-mail address:

This e-mail is my:

Home

Business

Payment

Payment method:

Credit Card PayPal

Additional Information

	Job Title:
	Company Name:
	Please list any UCLA Alumni Networks you are a member of:
	* Gender Pronoun:	*
	Do you have any accessibility requests?:
	* UCLA Affiliation:	*
Guest Information The following fields are required for all of your additional guests. If you are the main registrant, no need to include yourself below as we have your information above.
Your First Guest:
	* First Name:
	* Last Name:
	* Gender Pronoun:
	Do you have any accommodations requests?:
	* UCLA Affiliation:
	* Email address:
	* Alumnus/a of UCLA?:
	UCLA graduation year:
Your Second Guest:
	* First Name:
	* Last Name:
	* Gender Pronoun:
	Do you have any accommodations requests?:
	* UCLA Affiliation:
	* Email address:
	* Alumnus/a of UCLA?:
	UCLA graduation year:
Your Third Guest:
	* First Name:
	* Last Name:
	* Gender Pronoun:
	Do you have any accommodations requests?:
	* UCLA Affiliation:
	* Email address:
	* Alumnus/a of UCLA?:
	UCLA graduation year:
Your Fourth Guest:
	* First Name:
	* Last Name:
	* Gender Pronoun:
	Do you have any accommodations requests?:
	* UCLA Affiliation:
	* Email address:
	* Alumnus/a of UCLA?:
	UCLA graduation year:
Your Fifth Guest:
	* First Name:
	* Last Name:
	* Gender Pronoun:
	Do you have any accommodations requests?:
	* UCLA Affiliation:
	* Email address:
	* Alumnus/a of UCLA?:
	UCLA graduation year:
Your Sixth Guest:
	* First Name:
	* Last Name:
	* Gender Pronoun:
	Do you have any accommodations requests?:
	* UCLA Affiliation:
	* Email address:
	* Alumnus/a of UCLA?:
	UCLA graduation year:
Your Seventh Guest:
	* First Name:
	* Last Name:
	* Gender Pronoun:
	Do you have any accommodations requests?:
	* UCLA Affiliation:
	* Email address:
	* Alumnus/a of UCLA?:
	UCLA graduation year:
Your Eighth Guest:
	* First Name:
	* Last Name:
	* Gender Pronoun:
	Do you have any accommodations requests?:
	* UCLA Affiliation:
	* Email address:
	* Alumnus/a of UCLA?:
	UCLA graduation year:
Your Ninth Guest:
	* First Name:
	* Last Name:
	* Gender Pronoun:
	Do you have any accommodations requests?:
	* UCLA Affiliation:
	* Email address:
	* Alumnus/a of UCLA?:
	UCLA graduation year:

Comments: