SPEAKER FORMS

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

Contact Info, Bio, Itinerary

These forms are for faculty that have been invited to speak at the GSD Meeting and

are currently on the program agenda as chosen by the GSD Program Director.

Speaker Name *

Email Address *

Required entries with every submission*

CONTACT INFORMATION

Please list how you wish to be listed in the program

Mailing address

Office Phone

Mobile Phone

Home Phone

Fax

Assistant's Name

Assistant's Phone

Assistant's Email Address

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 and will arrange own grand transportation

Airport      Airline

Arrival date      Flight Number      Arrival Time

DEPARTURE

I DO / I DO NOT wish to be shuttled from the hotel to the airport and will arrange own grand transportation

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.  Make your accommodations reservation at the Ritz Carlton, Amelia Island by calling  800-241-3333 and book under the Georgia Society of Dermatologists room block. The room block EXPIRES May 3.

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

Cocktail Reception - Friday, 5:30 - 7:00 p.m., number attending

Children's Activity (ages 3 - 8), 5:30 - 7:00 p.m., number attending

Tween Movie Room (ages 8 - 14), 5:30 - 7:00 p.m., number attending

SATURDAY

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