Name

    Title

    Institution

    Street Address

    City, State, Zip

    Email

    Telephone

    Presentation Title(s)


    Speaker Release

    Please check the box next to each item below to acknowledge your acceptance.

    I agree to participate as a speaker in the Mountain Land Running Summit in Park City, Utah on September 23-25, 2021.

    I grant Mountain Land Rehabilitation the right to use my name, voice and presentation content, if Mountain Land Rehabilitation 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 Rehabilitation 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 Disclosure

    It is the policy of Mountain Land Rehabilitation 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: 2021 Mountain Land Running Summit
    Dates of CME Activity: September 23-25, 2021

    In 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 Support

    Consultant

    Speakers Bureau

    Stock Shareholder

    Other Financial or Material Support


    Attestation

    By checking this box, I attest that my presentation will be scientifically balanced and free of commercial bias or influence.


    Type your name and the date below to digitally sign this form and then click 'Submit'.

    Signature (type name)

    Date