Shape Up America!'s Diabesity™ Conference -- March 24-25, 2001

The Contributions of Diet and Inactivity to Diabesity™ in America: An Agenda for Action

Old Town Holiday Inn Hotel & Suites, 625 First Street, Alexandria, Virginia

***This Activity has been reviewed and is acceptable for up to 12.25 Prescribed credit hours by the American Academy of Family Physicians.

***This program has been reviewed and is approved for a maximum of 12.25 hours of clinical Category I (Preapproved) CME credit by the American Academy of Physician Assistants.  Physician assistants should claim only those hours actually spent participating in the CME activity.

***The conference has been approved for a total of 12 Continuing Professional Education Credits (CPEs) by the American Dietetic Association: Saturday, March 24th has been approved for 8 CPEs and Sunday, March 25th has been approved for 4 CPEs. The forms that must be signed by registered dieticians and registered dietetic technicians will be in the registration area at the close of sessions.

***Contact hours have been applied for with the Virginia Nurses Association.

PLEASE PRINT OUT THIS PAGE TO REGISTER.

TO REGISTER:
Please type or print clearly.  Use one registration form per person.  This form may be duplicated for additional registrants.
Fax or mail your registration form and payment to:
                Shape Up America!
                6707 Democracy Blvd, Suite 306
                Bethesda, MD  20817
                Fax: 301/493-9504

GENERAL INFORMATION:
Name:
Job Title/Dept.:
Affiliation:
Specialty (e.g., pediatric endocrinology):
Address:
City:
State:
Zip Code:
Telephone:
Fax:
E-mail:
Special needs or requirements (e.g., wheelchair accessibility), please describe:

 

 

 

 

MEETING REGISTRATION FEES:
Pre-Reg. (postmarked by Mar. 1) On-site Reg. (if available)
$300 $375

METHOD OF PAYMENT:

Check or money order (payable to Shape Up America!) enclosed in the amount of $_______

NOTE: Payments must be in U.S. funds drawn on a U.S. bank, minus all bank fees.

Visa; amount $_______

MasterCard; amount $_______

Discover; amount $_______

American Express; amount $_______
Cardholder's Name (please print):
Credit Card Number:
Expiration Date:
I authorize Shape Up America! to charge the total payment fee indicated on this form to my credit card.

Signature:

Date:
NOTE: Deadline for cancellation is 03/09/01.  A full refund, less a $50 administration fee, will be granted.

HOTEL INFORMATION:
Please call 703/548-6300 to reserve a room by 02/21/01 -- specify that you are a member of the Shape Up America! group for the block rate of $129.00, plus tax.
Shuttle service between the Old Town Holiday Inn Hotel & Suites and Reagan National Airport provided from 6:30 AM to 10:30 PM.  Please use the courtesy phone.
Taxi fare from National -- $10-$15; Dulles -- $50-$60; BWI -- $70-$80.