Presentation

Title: Req.

Upon completion of this presentation, the participant should be able to:

1.

2.

3.

I will need the following equipment for my presentation(s):

LCD Projector/Wireless Remote/Laser Pointer

Other AV needed:

I will be presenting via Microsoft Power Point and have NO integrated video in my presentation(s) (a laptop will be provided)

I will be presenting via Apple Keynote or other software (speaker must provide laptop to run onsite)

I have integrated video into my presentation file (speaker must provide laptop to run onsite)

I require ONLY voice amplification

I require sound amplification beyond my oration.  My presentation has sound that requires amplification.

IMPORTANT: As you are preparing your final presentation(s), in accordance with accreditation requirements, be sure to include a slide stating your financial disclosures, placed just after the title slide.

If you are using Microsoft Power Point and your presentation has NO integrated video, please mail us a copy of your final presentation(s) on CD ahead of the meeting.  Allowing the AV technician to have the presentations pre-loaded on our laptop ensures fewer delays and the meeting running on time.

I will mail a CD of my final presentation(s) by MAY 22 to GSDDS - 6134 Poplar Bluff Circle, Suite 101, Norcross, GA  30092

I will email my presentation(s) by MAY 22 to maryann@theassociationcompany.com

It is highly encouraged that you supplement your presentation slides with supporting documents, articles, research results, etc.  In lieu of passing out printed handouts during the meeting, we will be mailing CDs with PDFs of the presentations and any additionally provided handouts to all interested attendees after the meeting. 

YES, I will provide handouts and understand that they will be given to attendees via CD.  Please read the following disclaimer and "sign" your name to agree with the statements.

The undersigned Faculty (the “Undersigned”) agrees to:

1.  Grant to GSDDS a nonexclusive, irrevocable worldwide license to reproduce, make derivative works, publish, distribute, and/or sell the recording, transcript, and/or related materials of my presentation. This license does not prohibit the Undersigned from using this presentation in the future for his/her own professional or personal work.

2.  Warrant and represent that, to the best of Undersigned’s knowledge, nothing in the presentation violates the personal rights of others (including, without limitation, any copyright or privacy rights), is factual and contains nothing libelous or otherwise unlawful.

3.  Warrant and represent that the presentation is the Undersigned’s own original work, that Undersigned has the   authority to enter into this agreement, and the Undersigned is the sole copyright holder or that has attained all necessary licenses from any persons or organizations whose material is included or used in the presentation.

4.  Indemnify and hold harmless GSDDS from any claims for damages, costs or expenses arising from claims of copyright infringement resulting from the publication, sale, dissemination or distribution of any materials submitted and/or presented by the undersigned, either orally or in writing. The undersigned further agrees to indemnify GSDDS against any liability from any statements, oral or written, made by the Undersigned during or after this presentation.

Entering your name in the following space acts as my signature and agreement to the above statement:

Select one option below:

I will mail a CD of my handouts to GSDDS - 6134 Poplar Bluff Circle, Suite 101, Norcross, GA  30092.

I will email my handouts to maryann@theassociationcompany.com

Please acquire a copy of my final presentation from me at the meeting to use as my handout.

NO, I will not be providing handouts for the CD.

It is the policy of the GSDDS to comply with the Accreditation Council for Continuing Medical Education (ACCME) Standards for commercial support of CME activities.  All faculty are required to disclose to the program audience any real or apparent conflict(s) of interest related to this meeting or its content.  Having an interest in or affiliation with the corporate organization does not necessarily prevent you from making the presentation, but the relationship must be made known to the audience.  Failure to disclose or false disclosure will require the GSDDS to identify a replacement for your participation.

Use the following categories to indicate the type of financial relationships you are disclosing either for yourself or for you immediate family as defined above.  If an individual is uncertain about what might constitute a potential financial conflict or interest they should err on the side of full disclosure.

Please select one of the following two options

I DO NOT have any financial relationship to disclose.

OR

I have the following financial relationships to disclose:

Company/Organization:

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

    Code(s): C    E    L    O    P    S

I intend to reference unlabeled/unapproved uses of drugs or products in my presentation (specify drug(s) or product(s) by name for which the unlabeled use will be discussed.

I have read the Disclosure Requirements and to the best of my knowledge, the information provided on this form is true and correct and represents all items for disclosure.  I understand that failure to comply with the disclosure policy, when known and deliberate, may result in disqualification for two years in similar educational or related activities.  I agree to promptly notify the program directors is any of this information changes.    See Faculty Disclosure Statements

Entering your name in the following space acts as my signature and agreement to the above statement:

req.

Name , Relationship , Age (if under 18)

Name , Relationship , Age (if under 18)

Name , Relationship , Age (if under 18)

Name , Relationship , Age (if under 18)

Name , Relationship , Age (if under 18)

Guest expenses are the responsibility of the speaker.  Please list the names of your guests (spouse, children/ages, relatives, guests, etc.)

Sign me and/or my guests up for the following:

FRIDAY

Cocktail Reception - Friday, 6:00 - 7:30 p.m., number attending

Children's Activity (ages 3 - 8) - 6:00 - 7:30 p.m., number attending

Tween/Teen Movie Room (ages 9 - 14) - Friday, 6:00 - 7:30 p.m., number attending

SATURDAY

Resident's Luncheon - Saturday, 12:30 p.m., number attending

Family Party and Dinner - Saturday, 6:30 p.m., total number attending , ages of any children attending