REGISTRATION Fees
October 3–5, 2013 • Omni Shoreham Hotel • Washington D.C.
REGISTRATION FORM
Registration fee includes full attendance to main sessions, syllabus, continental breakfasts, lunch and breaks.
The deadline to register at lowest rate is July 21, 2013.
You can also register online at www.diabetesinnovation.org
Registration accepted on a space available basis until Oct 4, 2013.
Please print legibly or type to ensure accurate registration. One registrant per form, please—you may photocopy the form for others.
Special Code If you have been given a registration code as a supporter or sponsor, please enter it during the registration process online and your fee will automatically be adjusted or enter it on the registration page as indicated and subtract your discount from the fee.
First Name
Last Name
Degree
Company/Institution Title
Address
Special Accommodations In compliance with the Americans with Disabilities Act, Joslin Diabetes Center will make every reasonable effort to accommodate your needs during your attendance at this program. For any special requests, please contact Joslin Professional Education via email to Innovation@joslin.harvard.edu or call 1-888-567-5460 at least one week prior to the program date.
Registration & Cancellation Policy Registrations are accepted online until 11:59 pm ET October 1, 2013. To register after this date you must do so on-site. In case of cancellation, a full credit will be applied for use at a future Joslin Diabetes Center Conference or Diabetes Innovation 2014 and beyond. Written notification of your cancellation is required to process your credit.
Volunteer and Scholarship Opportunities Opportunities to volunteer and for scholarships may be available. Please e-mail Innovation@joslin.harvard.edu to find out more.
City
Zip/Postal Code
State/Province
Country
Telephone Fax
H Email (required for confirmation purposes)
Hotel Omni Shoreham Hotel 2500 Calvert Street, NW (at Connecticut Avenue) Washington, D.C. 20008 Tel: (202) 234-0700 www.omnihotels.com To secure accommodations and receive the negotiated special guest rate at the official conference hotel, please reserve by 5:00 PM EDT, Friday, September 13, 2013. To make your reservations, you can book online using the following hotel website link: www.omnihotels.com Or, if you prefer, you can also contact OMNI Reservations at 1-800-THE-OMNI (1-800-843-6664) or the hotel directly at 202-234-0700. Please identify yourself as attending the Joslin Diabetes Center— Diabetes Innovation 2013 meeting.
FEES
Early (until 7/21)
Advance (7/21-9/3)
Regular (9/3 onward)
Nonprofit
$595 r
$695 r
$795 r
Regular
$595 r
$895 r
$995 r
Special Code If you have been given a registration code as a supporter or sponsor, please enter it here ______________________________, and subtract the appropriate amount from the fee. Please indicate below by name of organization the supporter or sponsor who supplied you with the code: __________________________________________________________
PLEASE CHECK YOUR CHOICE IN THE TABLE ABOVE. AMOUNT DUE: $ ________________________________
Payment Options:
r Check (payable to Joslin Diabetes Center) r Credit Card: (check one)
r American Express r Master Card
r Discover r Visa
Name shown on card: (please print)
Credit Card Number
Exp Month Exp Year
Security Code
Signature Date
Please visit www.diabetesinnovation.org often for updates and new announcements 18
Diabetes Innovation 2013
Subject to change.
Please fax this form without a cover sheet to 1(617) 309-5925 Or mail with check enclosed to: Joslin Diabetes Center, Attn.: Teresa Bernardo, One Joslin Place, Boston MA 02215