SPEAKER FORMS

Contact Info, Bio, Itinerary | Educational Objectives | Presentation Requirements | Disclosure

Contact Info, Bio, Itinerary

Speaker Name *

Email Address *

Required entries with every submission*

CONTACT INFORMATION

Mailing address

Office Phone

Mobile Phone

Home Phone

Fax

Assistant's Name

Assistant's Phone

Assistant's Email Address

Please list how you wish to be listed in the program

BIO (used in the Meeting Program and excerpts taken for verbal introduction)

CME

I am seeking CME credit for this meeting 

I am NOT seeking CME credit for this meeting.

TRAVEL

I am driving to and from the meeting location (skip ahead to ACCOMMODATIONS)

I am FLYING to and from the meeting location (please complete Arrival/Departure info below)

 ARRIVAL

I DO / I DO NOT wish to be shuttled from the airport to the hotel

Airport      Airline

Arrival date      Flight Number      Arrival Time

DEPARTURE

I DO / I DO NOT wish to be shuttled from the hotel to the airport

Airport      Airline

Departure date      Flight Number      Departure Time

ACCOMMODATIONS

I have been told the GSD will make my room reservation at the resort.

OR

I understand I will be making my own room reservation at the resort.  800-SEA-ISLA

Please complete the following in either case,

I will be checking in on

I will be checking out on

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

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)

ACTIVITIES - sign me and/or my guests up for the following:

FRIDAY

Welcome Buffet Lunch in Exhibitor Hall - Friday, 11:30 a.m.-12:00 p.m., number attending

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

Luncheon - Saturday, 12:30 p.m., number attending (4 options, details to come)

Golf Tournament - Saturday, 12:30 p.m. (Players will pay the club directly.)  My handicap is

My spouse/guest will play too, Name , Handicap

I would also like to play with and/or

Family Hoe Down & Barbecue - Saturday, 6:30 p.m., total number attending , ages of any children attending