Outside of the Operatory

Celebrating Dentistry’s Leaders

Outside of the Operatory: Celebrating Dentistry's Leaders

Participate in the National Museum of Dentistry's newest online exhibition: Outside of the Operatory: Celebrating Dentistry's Leaders by sharing your story with the museum to be preserved and celebrated. The following form collects the influential stories of individuals that shaped the dental profession through organizational leadership.

Step 1 of 4

25%

Biographical Background

Name(Required)

Prefix First Middle Last Suffix

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email(Required)

Your address, phone, and email will only be used to contact you regarding your submission and any potential updates to your story. It will not be made public.

What was your relationship with oral health and dentistry growing up?

When did you become interested in oral health and dentistry?(Required)

Educational Background

Degree Program(Required)

Institution(Required)

Graduation Year(Required)

Please enter a number from 1900 to 2030.

Have you attended more than one educational program?(Required)

Yes

Degree Program

Institution

Graduation Year

Please enter a number from 1900 to 2030.

Have you attended more than two educational programs?

Yes

Degree Program

Institution

Graduation Year

Please enter a number from 1900 to 2030.

Have you attended more than three educational programs?

Yes

Other Educational Programs

Please provide any other educational programs you would like to include using the same format as above.

Advanced Training

Institution

Graduation Year

Please enter a number from 1900 to 2030.

Have you completed more than one advanced training?

Yes

Advanced Training

Institution

Graduation Year

Please enter a number from 1900 to 2030.

Your Legacy

Are you currently practicing dentistry?(Required)

Yes

I've never practiced dentistry

Are you currently practicing full-time or part-time?

Full-time

Part-time

When did you stop practicing dentistry?

Month

Day

Year

If the exact date is unknown, please enter the best approximation. If Month and Year are known, but day is not, please enter 1 for the day. If only the year is known, please enter 1 for the month and 1 for the day.

At what level(s) did you lead an organzation?(Required)

Student

Local (City or County)

State

Regional

National

International

Select all that apply.

What organization(s) did you lead and what position(s) did you hold?(Required)

How would you describe your legacy in 10 words or less?(Required)

Why did you choose to become an organizational leader?(Required)

Please include any motivation or other factors that lead to you becoming an organizational leader.

What is your legacy as an organizational leader?(Required)

Please include a brief overview of the people, places, events, initiatives, and dates that are important to your legacy.

What advice would you provide to someone interested in becoming an organizational leader?(Required)

Do you wish to provide any additional facts about your life story not otherwise requested?(Required)

Ex. family or cultural background, previous career, engagement in civic or entrepreneurial activities, sports, creative arts, etc.)

Yes

Additional facts about your life story:

Images & Consent

Do you wish to provide a high resolution image to be used as the image to identify you in your biographical profile?(Required)

Yes

Maybe, but please send me more information on how these images will be used and attributed

By choosing Yes and submitting your image, you are consenting to the Dr. Samuel D. Harris National Museum of Dentistry adding the digital files to its collection, and to utilize the image in the exhibition, educational programming, and marketing related to the exhibition as deemed appropriate by the museum.

Profile Image Upload

Max. file size: 50 MB.

Do you wish to provide additional images that showcase your legacy as a leader?(Required)

Yes

Maybe, but please send me more information on how these images will be used and attributed.

By choosing Yes and submitting these images, you are consenting to the Dr. Samuel D. Harris National Museum of Dentistry adding the digital files to its collection, and to utilize the images in the exhibition, educational programming, and marketing related to the exhibition as deemed appropriate by the museum.

Image(s) Upload

Drop files here or

Max. file size: 50 MB.

Would you like to receive updates on the Outside of the Operatory exhibit, this project, and the museum?(Required)

Yes

Would you like to receive information on how to further support the Outside of the Operatory initiative and the Dr. Samuel D. Harris National Museum of Dentistry?(Required)

Yes

Consent for Public Use of Information(Required)

I consent.

By checking this box, I authorize the Dr. Samuel D. Harris National Museum of Dentistry to share the provided information with the public and to use my name and any images provided, as well as my story in connection with the exhibition project and any educational or marketing material associated with the exhibition, unless otherwise stated within the form.

Agreement(Required)

I agree.

By checking this box, I understand that my completion of this form does not constitute my inclusion in the Outside of the Operatory exhibition. The museum reviews all entries before including the information in the exhibit, and may reach out to confirm or ask for additional information as necessary. The museum reserves the right to not include an entry into the exhibition, and will notify you of this reason if applicable.

hours

Tuesday - Friday: 10am to 4pm

Address

31 S. Greene St. Baltimore, MD 21201

Email

nmd@umaryland.edu

Phone

410-706-0600

The Dr. Samuel D. Harris National Museum of Dentistry is an auxiliary enterprise of the University of Maryland, School of Dentistry at the University of Maryland, Baltimore.

"*" indicates required fields

X/Twitter

This field is for validation purposes and should be left unchanged.

I would like more information about:*

The Museum

Gift Opportunities

Educational Programs

Collections

Name*

Email*