Pelvic Health Summit Speaker Disclosure & ReleasePlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *Title *Institution *Street Address *City, State, Zip *Email *Phone *Presentation Title(s) *Speaker ReleasePlease check the box next to each item below to acknowledge your acceptance.I agree to participate as a speaker in the Mountain Land Pelvic Health Summit in Park City, Utah on May 4-6, 2023.I grant Mountain Land Physical Therapy the right to use my name, audio/video reproduction and presentation content, if Mountain Land Physical Therapy chooses.I warrant that my presentation and any material(s) I submit do not infringe on the rights of others.I agree to obtain such permission(s) from the copyright owner(s) should my presentation or the material(s) I use during or in connection with my presentation require permission for use.I agree to inform any material co-authors of this presentation and obtain such permissions as needed.I understand that execution of this Agreement does not obligate Mountain Land Physical Therapy to publish my presentation or the materials used therein.I verify that I am the author of this presentation, I have authority to enter into this agreement and that I will be bound by its terms.Full DisclosureIt is the policy of Mountain Land Physical Therapy to ensure balance, independence, objectivity and scientific rigor in all programs it provides. Everyone in a position to control the content of an educational activity must disclose all relevant financial relationships with commercial interests. The information you provide addresses several requirements of the national accreditation boards (ACCME, ACPE, etc.) regarding independence from commercial interests. This information must be disclosed to participants prior to the beginning of the activity. Lastly, all conflicts of interest must be resolved prior to the educational activity. The ACCME defines "relevant" financial relationships as financial relationships in any amount occurring within the past 12 months that create a conflict of interest. (2.1) An individual who refuses to disclose relevant financial relationships will be disqualified from being a planning committee member, a teacher, or an author of CME, and cannot have control of, or responsibility for, the development, management, presentation or evaluation of the CME activity. (2.2) Title of CME Activity: 2023 Mountain Land Pelvic Health Summit Dates of CME Activity: May 4 - 6, 2023In the past 12 months, have you (or spouse/partner) had a financial relationship with a commercial organization that produces, markets, re-sells, or distributes health care goods or services consumed by, or used on patients, and which is relevant to the content of this educational activity?NoYesIf yes, please list the name and your role with the commercial interest, manufacturer or service provider for each of the following affiliation/financial interests:Grant/Research SupportConsultantSpeakers BureauStock ShareholderOther Financial or Material SupportAttestationBy checking this box, I attest that my presentation will be scientifically balanced and free of commercial bias or influence.SignatureClear SignatureDateSubmit
