Download Membership Application to fax or mail to ODHA.

	Please note that Professional liability insurance as a member benefit will be in effect for ODHA members for the calendar year beginning January. Members are responsible for ensuring that they meet the liability insurance requirements of the College of Dental Hygienists of Ontario (CDHO). If you have any questions, please contact the ODHA office. Please note: We have reached the first 200 online active membership registrations for the 2010-2011 membership year. Please Note: You are renewing/New membership on 06-Sep-2010 for: Membership Year: 2010-2011 Membership Period: 01-Nov-2010 to 31-Oct-2011  All items marked by an * are required. Page 1 of 5 Section 1: Member Profile Membership #: New      CDHO #: Current Membership: N/A Title: Dr. Drs. Madam Master Miss Mme. Mr. Mrs. Ms. Prof. First Name:* Middle Name: Last Name:* Usual First Name: Previous Name: Birth Date:* Year: 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 Month: January February March April May June July August September October November December Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Gender:* Female       Male Year of Graduation:* (Dental Hygiene Program) Name of Institution: Algonquin College of Applied Arts and Technology APLUS Institute of Technology, Healthcare and Business Aurora Dental College Cambrian College of Applied Arts and Technology Camosun College Canadian Academy of Dental Hygiene Canadian Armed Forces Dental Services Canadian Business College Canadian Institute of Dental Hygiene Canadian National Institute of Health Canadore College of Applied Arts and Technology CÉGÈP Collège Trois-Rivières CÉGÈP de Chicoutimi CÉGÈP François Xavier-Garneau CÉGÈP Saint-Hyacinthe Collège Boréal Collège de l’Outaouais Collège Edouard-Montpetit Collège Maisonneuve College of New Caledonia Confederation College of Applied Arts and Technology Dalhousie Univeristy Durham College of Applied Arts and Technology Erie Community College Fanshawe College of Applied Arts and Technology George Brown College of Applied Arts and Technology George Yonge College Georgian College of Applied Arts and Technology John Abbott College La Cité Collégiale London Healthcare Technology College Maxwell College Medix, Brampton Medix, Kitchener Niagara College Ontario Dental Education Institute Other Oxford College of Arts, Business and Technology Oxford North Toronto RCC Institute Technology (formerly Yorkville) Regency Dental Hygiene Academy Saskatchewan Institute of Applied Arts and Technology School of Dental Hygiene, Dalhousie University Select Institution: Seneca College of Applied Arts and Technology St. Clair College of Applied Arts and Technology Toronto College of Dental Hygiene and Auxiliaries Trillium College, Burlington Trillium College, Kingston Trillium College, Oshawa Trillium College, Ottawa Trillium College, Toronto University of Alberta University of British Columbia University of Manitoba University of Toronto Vancouver Community College Xincon College No. of Years of Membership: Email: Preferred Mailing Address: * Home Primary Business or Employer Home Address: Home Address: City: Province or Territory: ON Postal Code:   Country: Canada Home Phone: Cellular Phone: Primary Business or Employer Information: Business or Employer Name: Type and Status: Employment Type: Self Employed Employee Volunteer Other Employment Status: Full Time Part Time Occasional Other Address: City: Province or Territory: ON Postal Code:   Country: Canada Business or Employer Phone:  Ext. Business or Employer Fax: Secondary Business or Employer Information: Business or Employer Name: Type and Status: Employment Type: Self Employed Employee Volunteer Other Employment Status: Full Time Part Time Occasional Other Address: City: Province or Territory: ON Postal Code:   Country: Canada Business or Employer Phone:  Ext. Business or Employer Fax: Are you working at more than two places ?   Yes    No Privacy Consent: Please Note: Ontario Dental Hygiene Societies are considered "third parties" and will not receive your contact information if you select "I do not consent" I consent to the use and disclosure of my name and mailing address for the purposes of third party mailings. I do not consent to such use and disclosure. Login Information: Login ID: New Password: (Max. 25 characters) Confirm Password: