Crisis: Preparedness, Mobilization, Sustainability
A Look at Diabetes and the Haitian Relief Efforts

Date: Saturday, November 6, 2010

Location: New York Academy of Medicine, 1216 Fifth Avenue, New York City

Conference Registration Form

Please type / print clearly the following information:

Name *
Title *
Organization *
Street Address *
City *
    State: *    Zip: *
Telephone *
 Fax:
Email Address *
Quantity Before Oct 15 After Oct 14 Amount
Full Conference Fee (Member) $125 $150
Full Conference Fee (Non-Member) $150 $200
Residents (with letter shown onsite) $ 50 $ 75
Award Reception Only $ 50 $ 75
Students (must show school ID onsite) $ 0 $ 0
* A portion of this fee goes towards sponsoring student attendees.
Yes, we will have an exhibit space (includes 1 conference registration) $2,500
Sponsoring Company
Special Needs / Dietary
Grand Total

Ways to Register

  1. By Check
    - Print and send completed form with payment to ESMA, 49 West 127th Street, Harlem, NY 10027 no later than October 28th.

  2. By Credit Card
    - Complete the above registration form and click Submit Registration button below or call 212.690.1363

    Limited free parking is available onsite. Additional parking at: Merit Parking; 107th Street (bet. 5th & Madison Ave.)

Accreditation: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of The New York Academy of Medicine and the Empire State Medical Association. The New York Academy of Medicine is accredited by the ACCME to provide continuing medical education for physicians. The New York Academy of Medicine designates this educational activity for maximum of 3.0 Category 1 credits toward the Physician's Recognition Award of the AMA. Each physician should claim only those credits that he/she actually spent in each activity. Disclosure Policy: The New York Academy of Medicine relies upon invited faculty participants to provide educational information that is objective and as free from bias as possible. In this spirit and in accordance with the guidelines of the session sponsor, faculty participants are required to indicate any commercial relationship that might be perceived as a real or apparent conflict of interest. Persons who have not completed a conflict of interest disclosure form will not participate as faculty. Any presenter with disclosed relationships that prove to create a conflict of interest with regard to their contribution to the activity will not be permitted to present. The Academy also requires that faculty participating in any CME activity disclose when discussing any unlabeled or investigational use of any commercial product or device not yet approved for use in the United States.