{"id":7260,"date":"2021-11-16T09:33:24","date_gmt":"2021-11-16T14:33:24","guid":{"rendered":"https:\/\/www.michigandental.org\/?page_id=7260"},"modified":"2021-12-03T16:29:30","modified_gmt":"2021-12-03T21:29:30","slug":"mda-speaker-information-form","status":"publish","type":"page","link":"https:\/\/www.michigandental.org\/mda-speaker-information-form\/","title":{"rendered":"MDA Speaker Information Form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_67' ><div id='gf_67' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Speaker Information Form<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_67'  action='\/wp-json\/wp\/v2\/pages\/7260#gf_67' data-formid='67' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LcHpTIrAAAAAG71geNZWhEl5aFSv1vz-QYc-Xz3' data-tabindex='0'><input id=\"input_5afe557e4679edd2d3e6a1cc5529cb3c\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_5afe557e4679edd2d3e6a1cc5529cb3c\" value=\"\"\/><\/div> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><div id='gform_fields_67' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_67_14\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Speaker Information<\/h3><\/div><fieldset id=\"field_67_2\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >NAME<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_67_2'>\n                            \n                            <span id='input_67_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_67_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_67_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_67_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_67_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_67_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_67_3\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_3'>CREDENTIALS<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_67_3' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_67_4\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_4'>YOUR TITLE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_67_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_67_5\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >MAILING ADDRESS<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_67_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_67_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_67_5_1' value=''    aria-required='false'    \/>\n                                        <label for='input_67_5_1' id='input_67_5_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_67_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_67_5_2' value=''     aria-required='false'   \/>\n                                        <label for='input_67_5_2' id='input_67_5_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_67_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_67_5_3' value=''    aria-required='false'    \/>\n                                    <label for='input_67_5_3' id='input_67_5_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_67_5_4_container' >\n                                        <select name='input_5.4' id='input_67_5_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_67_5_4' id='input_67_5_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_67_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_67_5_5' value=''    aria-required='false'    \/>\n                                    <label for='input_67_5_5' id='input_67_5_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_5.6' id='input_67_5_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_67_6\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_6'>WORK PHONE<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_67_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_67_8\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_8'>CELL PHONE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_67_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_67_9\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_9'>EMAIL<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_67_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_67_10\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_10'>ADA NUMBER (Dentists Only)<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_67_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_67_11\" class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_67_11'>UPLOAD YOUR W-9<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_67_11' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_67_11&quot;,&quot;container&quot;:&quot;gform_multifile_upload_67_11&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_67_11&quot;,&quot;filelist&quot;:&quot;gform_preview_67_11&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.michigandental.org\\\/?gf_page=d3cdb8b5fe9c89b&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.michigandental.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.michigandental.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;pdf,jpg,png&quot;}],&quot;max_file_size&quot;:&quot;2097152b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:67,&quot;field_id&quot;:11},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_67_11&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_67_11' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_67_11' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_67_11\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_67_11'>Accepted file types: pdf, jpg, png, Max. file size: 2 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_67_11'><\/ul> <div id='gform_preview_67_11' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_67_13\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Equipment Requirements<\/h3><\/div><div id=\"field_67_16\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_16'>What type of laptop will you be using?<\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_67_16' class='large gfield_select'     aria-invalid=\"false\" ><option value='Choose One' >Choose One<\/option><option value='Apple' >Apple<\/option><option value='Windows' >Windows<\/option><\/select><\/div><\/div><div id=\"field_67_17\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_17'>Please list all audio\/visual requirements you will need for your presentation, including microphone type.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_67_17' class='textarea large'  aria-describedby=\"gfield_description_67_17\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_67_17'>(NOTE: Speakers are required to bring their own laptop.)<\/div><\/div><div id=\"field_67_18\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Housing Requirements<\/h3><\/div><div id=\"field_67_19\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>The Michigan Dental Association normally pays for your room the night before your presentation unless contract specifies otherwise. The MDA is not responsible for additional nights or additional in-room person charges or expenses.<\/p><\/div><div id=\"field_67_21\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_21'>NUMBER OF NIGHTS REQUIRED<\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_67_21' class='large gfield_select'     aria-invalid=\"false\" ><option value='Choose One' >Choose One<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><\/select><\/div><\/div><div id=\"field_67_23\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_23'>NAME(S) OF ACCOMPANY GUESTS<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_67_23' type='text' value='' class='large'  aria-describedby=\"gfield_description_67_23\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_67_23'>Separate names with commas.<\/div><\/div><div id=\"field_67_24\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_24'>SPECIAL REQUESTS<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_67_24' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_67_25\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Biographical Information<\/h3><\/div><div id=\"field_67_26\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_26'>Enter your preferred wording (150 words or less) describing your background, accomplishments, and qualifications.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_26' id='input_67_26' class='textarea large'   maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_67_27\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Course Information<\/h3><\/div><div id=\"field_67_28\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Please input your suggested wording in 150 words or less, a synopsis\/summary of your program (including bulleted learning objectives) that can be used for publication purposes. <strong>NOTE: The MDA will shorten the synopsis to fit space requirements.<\/strong> Include the following information:<\/p>\n<ul>\n<li>Bulleted learning objectives (minimum of three).<\/li>\n<li>Unique aspects of the program.<\/li>\n<li>Any benefits the audience will derive from attending this program.<\/li>\n<li>Who will benefit from this program (i.e. dentists, hygienists, assistants, business staff).<\/li>\n<li>The immediate \u201cpay-offs\u201d to attending the program.<\/li>\n<\/ul><\/div><div id=\"field_67_29\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_29'>FIRST COURSE TITLE<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_67_29' type='text' value='' class='large' maxlength='100' aria-describedby=\"gfield_description_67_29\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_67_29'>NOTE: Titles must be kept under 100 characters (including spaces).<\/div><\/div><div id=\"field_67_31\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_31'>FIRST COURSE DESCRIPTION<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_67_31' class='textarea large'  aria-describedby=\"gfield_description_67_31\" maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_67_31'>NOTE: Course descriptions must be 1,000 characters (including spaces) or less.<\/div><\/div><fieldset id=\"field_67_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >AUDIENCE (First Course)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_67_30'><div class='gchoice gchoice_67_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='DDS'  id='choice_67_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_30_1' id='label_67_30_1' class='gform-field-label gform-field-label--type-inline'>DDS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Assistants'  id='choice_67_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_30_2' id='label_67_30_2' class='gform-field-label gform-field-label--type-inline'>Assistants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='Hygienists'  id='choice_67_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_30_3' id='label_67_30_3' class='gform-field-label gform-field-label--type-inline'>Hygienists<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_30_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.4' type='checkbox'  value='Entire Dental Team'  id='choice_67_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_30_4' id='label_67_30_4' class='gform-field-label gform-field-label--type-inline'>Entire Dental Team<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_67_32\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><hr><\/div><div id=\"field_67_33\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_33'>SECOND COURSE TITLE<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_67_33' type='text' value='' class='large' maxlength='100' aria-describedby=\"gfield_description_67_33\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_67_33'>NOTE: Titles must be kept under 100 characters (including spaces).<\/div><\/div><div id=\"field_67_34\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_34'>SECOND COURSE DESCRIPTION<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_67_34' class='textarea large'  aria-describedby=\"gfield_description_67_34\" maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_67_34'>NOTE: Course descriptions must be 1,000 characters (including spaces) or less.<\/div><\/div><fieldset id=\"field_67_35\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >AUDIENCE (Second Course)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_67_35'><div class='gchoice gchoice_67_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='DDS'  id='choice_67_35_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_35_1' id='label_67_35_1' class='gform-field-label gform-field-label--type-inline'>DDS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='Assistants'  id='choice_67_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_35_2' id='label_67_35_2' class='gform-field-label gform-field-label--type-inline'>Assistants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_35_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.3' type='checkbox'  value='Hygienists'  id='choice_67_35_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_35_3' id='label_67_35_3' class='gform-field-label gform-field-label--type-inline'>Hygienists<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_67_35_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.4' type='checkbox'  value='Entire Dental Team'  id='choice_67_35_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_67_35_4' id='label_67_35_4' class='gform-field-label gform-field-label--type-inline'>Entire Dental Team<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_67_36\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Course Handouts<\/h3><\/div><div id=\"field_67_37\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Please view the MDA's <a target=\"_blank\" href=\"https:\/\/annualsession.michigandental.org\/wp-content\/uploads\/Speaker-Handout-Rules.pdf\">Speaker Handout Rules<\/a>.<\/p><\/div><fieldset id=\"field_67_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Will your handout originals be sent to the MDA 30 days in advance of program for copying (CE seminar) or posting online (Annual Session)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_67_38'>\n\t\t\t<div class='gchoice gchoice_67_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Yes'  id='choice_67_38_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_67_38\"   \/>\n\t\t\t\t\t<label for='choice_67_38_0' id='label_67_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_67_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_67_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_67_38_1' id='label_67_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_67_38'>NOTE: MDA does not reimburse for copying. Materials must be received 30 days prior to program date either by mail or email.<\/div><\/fieldset><div id=\"field_67_39\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>File Upload:<\/strong> Use the feature below to include your presentation handouts with this form submission. Submit all handouts in PDF format. For Powerpoint presentations, choose the 3 Slides choice in your Print Options menu before converting to PDF. <strong>NOTE: Name your handouts to match your course title.<\/strong><\/p><\/div><div id=\"field_67_40\" class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_67_40'>UPLOAD HANDOUT(S) (First Course)<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_67_40' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_67_40&quot;,&quot;container&quot;:&quot;gform_multifile_upload_67_40&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_67_40&quot;,&quot;filelist&quot;:&quot;gform_preview_67_40&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.michigandental.org\\\/?gf_page=d3cdb8b5fe9c89b&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.michigandental.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.michigandental.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;pdf&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:67,&quot;field_id&quot;:40},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_67_40&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_67_40' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_67_40' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_67_40\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_67_40'>Accepted file types: pdf, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_67_40'><\/ul> <div id='gform_preview_67_40' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_67_41\" class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_67_41'>UPLOAD HANDOUT(S) (Second Course)<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_67_41' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_67_41&quot;,&quot;container&quot;:&quot;gform_multifile_upload_67_41&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_67_41&quot;,&quot;filelist&quot;:&quot;gform_preview_67_41&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.michigandental.org\\\/?gf_page=d3cdb8b5fe9c89b&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.michigandental.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.michigandental.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;pdf&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:67,&quot;field_id&quot;:41},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_67_41&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_67_41' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_67_41' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_67_41\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_67_41'>Accepted file types: pdf, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_67_41'><\/ul> <div id='gform_preview_67_41' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_67_42\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Photograph<\/h3><\/div><div id=\"field_67_43\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>The MDA requires a high-resolution, color, professional portrait (see examples below).  Please follow these guidelines:<\/p>\n\n<ul>\n<li>Send the original digital image.<\/li>\n<li>Do not send an image copied from your website.<\/li>\n<li>Only send .jpg  or .png images.<\/li>\n<\/ul>\n\n<p>Photos meeting these requirements can be attached to this form using the upload option below. If you must send a printed image by mail, please write your name on the back. <strong>NOTE: Photos will not accompany course descriptions of speakers who do not send images meeting these requirements.<\/strong><\/p>\n\n\n<p><img decoding=\"async\" class=\"aligncenter size-full wp-image-5811 lazyload\" data-src=\"https:\/\/michigandental-org.mystagingwebsite.com\/wp-content\/uploads\/2021\/11\/prof_portrait_examples2.png\" src=\"data:image\/svg+xml;base64,PHN2ZyB3aWR0aD0iMSIgaGVpZ2h0PSIxIiB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciPjwvc3ZnPg==\" \/><\/p>\n&nbsp;<\/div><div id=\"field_67_44\" class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_44'>UPLOAD PHOTO<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_44' id='input_67_44' type='file' class='large' aria-describedby=\"gfield_upload_rules_67_44\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_67_44'>Accepted file types: jpg, png, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_67_44'><\/div> <\/div><\/div><div id=\"field_67_45\" class=\"gfield gfield--type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_67_45'>CAPTCHA<\/label><div id='input_67_45' class='ginput_container ginput_recaptcha' data-sitekey='6LeJbVAbAAAAAJgc73kmJg1pEX02-6B9YrTKGeH_'  data-theme='light' data-tabindex='-1' data-size='invisible' 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