Student Membership Application

Students holding full or part time student status in a dental school, program or course, lasting at least three months, may apply for ADAA Student Membership.

Note that student members are not automatically covered by liability insurance, but have the option of adding the coverage below, at only $10 per year.
Attn Instructors: Schools may pay with one check for multiple students. Complete a student application for every student, print a copy of the application at the end and mail them all along with a check to ADAA for the total amount. Email Jennifer Porter at jporter@adaausa.org if you would like ADAA student pins mailed to you. Include the # of registered students for your school, and a mailing address.
Attn Students: If you would like a student pin mailed to you after completing this form, send a request to info@adaausa.org.
How did you learn about ADAA?
 If other, please specify:

Contact Information

First Name
Middle
Last Name
Suffix
Email
Mailing Address *Be sure to include Apt or Unit # in the address field, if applicable.
Address
City
State
Zip Code
Phone
Business Phone

Student Membership

Students pay $35 for membership and an additional, optional $10 for professional liability insurance.
All Memberships are for a full year (365 days) from the time the dues payment is processed. Membership, professional liability insurance (if applicable) and accidental death insurance (if applicable) become effective following receipt and processing of application.
By Joining the ADAA, you also become a member of a state organization and a local organization if one exists. ADAA will submit your information to the appropriate state and/or local associations. Local membership will be in the same state as state membership.
SCHOOL INFORMATION
If you do not see your school on this list, please email techsupport@adaausa.org to have it added before submitting your application. Include the school name, address, phone number and Instructor's (or program director's) name and email address in your email.
Choose the school you are attending:
School
Enter your expected graduation date. If you only know the month, enter the first day of the month, example: 06/01/2022.
Graduation Date ?
By checking this box you are confirming that you are a student currently enrolled in this institution.
Yes, I am currently enrolled at this institution.
National Dues
Membership Category
State Dues
Please choose the Primary State Association and any additional State Associations you wish to join below. The Primary State Association should be the same state you live in. You will be charged state dues for every state you select.
AK - $4
AL - $4
AZ - $4
AR - $4
CA - $4
CO - $4
CT - $4
DE - $4
DC - $4
FL - $4
GA - $4
HI - $4
ID - $4
IL - $4
IN - $4
IA - $4
KS - $4
KY - $4
LA - $4
ME - $4
MD - $4
MA - $4
MI - $4
MN - $4
MS - $4
MO - $4
MT - $4
NE - $4
NV - $4
NH - $4
NJ - $4
NM - $4
NY - $4
NC - $4
ND - $4
OH - $4
OK - $4
OR - $4
PA - $4
RI - $4
SC - $4
SD - $4
TN - $4
TX - $4
UT - $4
VT - $4
VA - $4
WA - $4
WV - $4
WI - $4
WY - $4
Primary State Chapter
Choose your Primary State Chapter below. The State Chapter should be the same state you live in. Please choose ONE from the drop down list below.
State Chapter Association
Local Association
Choose your Primary Local Chapter from the list below. The list is in order by state name. Locals are listed under each state. The Local Chapter (if there is one) should be in the same state as your primary state. Please choose ONE from the drop down list below. Note: if there isn't a local chapter in your state, choose the state chapter only option. Ex: for Maryland, choose, "Maryland State Chapter Only".
Local Chapter 1

Professional Liability Insurance

Professional Liability Insurance can be added on to any Student membership for an extra $10.00. Please indicate below if you wish to purchase insurance.
Yes, I would like to purchase Liability Insurance for $10.00

Membership Plaques

Membership Plaques are available for purchase. They come with a current year decal and are not engraved. Plaques are mailed out twice a month via USPS and can take up to three weeks for delivery.
Membership Plaque $40 (optional)

NO PORTION OF ADAA FEES ARE REFUNDABLE OR TRANSFERABLE * Student Membership includes a subscription to The Dental Assistant, access to the ADAA E-Learning courses through BizLibrary (access will be given the morning after you join or renew after 8:00am Central), $50,000 professional dental assisting liability insurance (if paid for/applicable), a premium job board and much more. * ALL MEMBERSHIPS ARE FOR ONE FULL YEAR. BY SUBMITTING THIS APPLICATION YOU AGREE TO ONE FULL YEAR OF MEMBERSHIP WHICH CANNOT BE CANCELLED OR REFUNDED. "* Monthly, Quarterly, and Semi Annual payment options are not available at this time.
   - denotes required fields