FUTURE OF DENTAL HYGIENE COMMITMENT FORM

GDHA is setting up a separate legislative communication network for hygienists to receive legislative information.
(Print, fill out, and mail only if you want to receive legislative information)

As a concerned Registered Dental Hygienist, I make the following commitment to be legislatively active for the profession of dental hygiene. (check all that apply):

  1. I want to receive legislative information. ____
  2. I will be a member of ADHA, GDHA and component. ____ Need application. ___
  3. I will contact my Representative and Senator by phone, fax, email, letter, visit. ____
  4. I will promptly contact my legislators when called upon by GDHA. ____
  5. I will come to the Capital in Atlanta to lobby. ____ I am available on: M T W R F
  6. I will contact Committee members of the legislature. ____
  7. I will provide testimony at hearings. ____
  8. I will attend hearings in presence only. ____
  9. I will adjust my work schedule to come to hearings. ____
  10. I will make a financial contribution to GDHA. ____
  11. I will call 4 hygienists on the phone tree network and pass message along. ____
  12. I will be a GDHA primary contact for my legislators. ____

My House Representative is: ___________________ My Senator is: _______________

If you know other Legislators, please list: _____________________________________________

My friends and family know: _______________________________________________________

If you are a member of another association or group that has lobbying forces, please list:

________________________________________________________________________

If you know of someone who is a member of any healthcare, public health advocacy group, list:

________________________________________________________

List any comments or additional information on back of page.

Your Name ______________________________________

Address _________________________________________

City, Zip _________________________________________

Phone (H)___________________(W)___________________

Fax (H)_____________________(W)___________________

Email ___________________________________________

ADHA member____ Non-member____

Return to: Cheryl Haynes, RDH
3374 Stone Path Way
Powder Springs, GA 30127