REGISTRATION FORM – ABSTRACT AUTHORS (Page 1 of 2) Early Bird Registration Deadline for Deadline to Deadline to Register Registration opens in Abstract Authors Register by Mail Online Orlando May 13, 2010 June 4, 2010 June 17, 2010 June 24, 2010 ADA Registration will e-mail or fax a confirmation of your registration within 72 hours of receipt of your form. For accurate and easy registration you may visit http://scientificsessions.diabetes.org to register online. FAX: (415) 979-2249 MAIL: ADA Registration QUESTIONS: Phone: (Mon-Fri, 9am-9pm ET) c/o CMR (866) 290-9910 (US & Canada) 33 New Montgomery, Suite 1100 (415) 268-2086 (International) San Francisco, CA 94105 E-mail: email@example.com ADA reserves the right to accept, reject or condition acceptance, based on ADA’s sole discretion, for any reason, which need not be disclosed to the applicant. By registering for this event, attendee agrees to hold harmless ADA and the Facilities for any damages or injuries to property or individuals that may occur during the conference. Attendee also agrees that ADA may use and distribute your image, name and voice in all forms and media. Photography, including camera-enabled cellphones, videotaping and audiorecording in session rooms, workshops and the Poster Hall is forbidden. I. PERSONAL INFORMATION (please print or type clearly) First Name: Middle Initial: Last Name: Academic Degree(s): DO DPM MD MD,PhD NP PA PhD RD RN RPH/PharmD Other (please specify): Company/Institution (for badge): Mailing Address (please check one) Business Home Street Address: City: State/Province: Zip/Postal Code: Country: Phone: Fax: E-mail*: Please send a copy of the registration to: Additional E-mail: In case of an emergency during the meeting, please contact: First Name: Last Name: Phone: Relationship: Will this person be staying in your hotel room? Yes No Check here if you require special assistance to fully participate in the meeting (please attach a separate sheet to indicate needs). *E-mail address is required - this unique identifier will be used for tracking continuing education credits. II. REGISTRATION FEES (please check one) Abstract Authors are extended the Early Bird Registration rate until May 13, 2010. EARLY BIRD ON-SITE Between 12/2/09-5/13/10 Between 5/14/10-6/29/10 ADA Member** $395 $515 New or Renewing Member $395 $515 Non-Member $570 $705 Student/Resident/Fellow $245 $280 Available to people currently enrolled in one of these programs. Proof of status in program must be supplied by institution along with your registration form. Guest (Spouse/Family Member) $100 $100 $100 Guest’s First Name: Guest’s Last Name: One guest per full meeting registration is allowed. Guest registration includes entrance to the Exhibit Hall, Poster Hall and non-ticketed Social Events only. Guests are not eligible for continuing education credit. Children under the age of 18, even if paid registrants, will not be admitted to the Exhibit Hall or Session rooms. **In order to qualify for the member rate you must list your 15-digit Member ID Number and be a member through June 30, 2010. III. MEMBERSHIP DUES ADA Members: Professional Member ID Number - New or Renewing Members: (Please check one) Category I: Physicians, researchers, others: Category II: Dietitians, diabetes educators, nurses, others: Includes one of the two journals listed (choose one): Includes journals - Diabetes Spectrum® and Diabetes Forecast® Diabetes® Diabetes Care® Regular, US/Mexico $295.00 Regular, US/Mexico $135.00 Regular, Canada $309.75 (includes GST) Regular, Canada $141.75 (includes GST) Regular, International $395.00 (outside North America) Regular, International $195.00 (outside North America) In-Training*, US/Mexico $175.00 In-Training*, US/Mexico $75.00 In-Training*, Canada $183.75 (includes GST) In-Training*, Canada $78.75 (includes GST) In-Training*, International $275.00 (outside North America) In-Training*, International $125.00 (outside North America) *Training dues rates are reserved for professionals that have received their first professional degree, diploma or certificate within the last 5 years. If you quality for this special rate, please reference your Training information below. University or College attended: Degree (s): Date Earned: Continued (Page 2 of 2) Attendee Name (first name, middle initial, last name): IV. ADDITIONAL ITEMS 2010 Orlando City Pin: Donation to the ADA Research Foundation: $ (quantity) x $5.00 = $ Donate $20 for a 5K@ADA T-Shirt (must register separately for this ‘I Decide’ Charm: event): (quantity) x $9.95 = $ (quantity) x $20.00 = $ Shuttle Pass (for those who do not book through ADA Size (Men’s): XSM SM M L XL XXL Housing): (quantity) x $50.00 = $ Webcasts: Order now to get the lowest possible price for access to the official Opening Reception – Epcot Center (Friday, June 25th): webcasts of presentations at Scientific Sessions 2010 Prior to May 13, 2010 - Members Attendee (limit of 1) x $20.00 = $ On-line access only - $160.00 = $ Registered Guest (limit of 1) x $20.00 = $ On-line access with USB - $215.00 = $ Non-Registered Guests (limit of 3) x $40.00 = $ On-line access with USB and mailed via DHL - $245.00 = $ After May 13, 2010 - Non-Members Attendee (limit of 1) x $35.00 = $ On-line access only - $210.00 = $ Registered Guest (limit of 1) x $35.00 = $ On-line access with USB - $265.00 = $ Non-Registered Guests (limit of 3) x $50.00 = $ On-line access with USB and mailed via DHL - $315.00 = $ V. PROFESSIONAL INFORMATION (please check one answer to each question) Please list your Abstract Publication Number(s): Please indicate type of Abstract Author: Oral Poster President Poster I consider myself primarily a: Clinician Educator Industry Scientist Specialty Area: Adult Endocrinology Basic Science Cardiology Dietetics Epidemiology Family Practice Geriatrics Internal Medicine Nephrology Neuropathy Nursing Obstetrics/Gynecology Ophthalmology Pediatric Endocrinology Pharmacy Podiatry Psychology Public Health Other (please specify): Place of work: Academic Administration Corporate/Industry Government/Military Hospital Managed Care Private Practice Other (please specify): Which session track are you Acute and Chronic Complications Behavioral Medicine, Clinical Nutrition, Education, Exercise most interested in? Clinical Diabetes/Therapeutics Epidemiology/Genetics Immunology/Transplantation Insulin Signaling/Insulin Action Integrated Physiology or Obesity Islet Biology/Insulin Secretion Scientific Sessions Attendance: Attend only East Coast Attend every 2-3 years Attend each year First Time How did you learn about this meeting? ADA E-News ADA Web Site Colleague Journal Advertisement Mailing Previous Attendance Other (please specify): If referred by a colleague, please provide the first and last name of the colleague: If by mailing, enter the registration code listed on the brochure below your address: VI. PAYMENT INFORMATION Registration Fees $ . + Membership Dues $ . + Additional Items $ . = Total Amount Due $ . Checks and money orders must be payable to the American Diabetes Association and must be drawn on a U.S. bank, in U.S. dollars. Check/Money Order #______ Visa MasterCard Discover American Express Credit Card Number: Exp. Date (MM/YY): / Billing Street Address: Billing Zip/Postal Code: Name as it appears on card: Signature: VII. CHANGES OR CANCELLATIONS Name changes and substitutions are not permitted. All cancellation and refund requests must be made in writing and sent via e-mail to firstname.lastname@example.org or faxed to (415) 979-2249. For a full refund (less a $50 administrative fee) cancellation requests must be received on or before March 11, 2010. Cancellation requests received between March 12, 2010 and May 13, 2010 will receive a refund of 50% of the registration fee. Cancellation requests received after May 13, 2010 will not receive a refund of the registration fee. Abstract Authors who register early but their abstract is not accepted for presentation may cancel the registration and receive a full refund (less a $50 administrative fee) up to May 13, 2010. City Pins,‘I Decide’ Charms, and ADA Research Foundation donations are non-refundable. Webcasts and Shuttle Passes will be fully refundable if cancelled prior to June 24, 2010. Opening Reception tickets and 5K@ADA T-Shirts will be fully refundable if cancelled prior to May 13, 2010. Cancellations after May 13, 2010 will receive a refund of 50% of the value of the ticket or shirt. All attempts will be made to process refunds within 30 days of receipt. ADA will correct any errors when calculating the total amount due.