Click on the first link titled "Speaker Disclosures of Financial Relationships" on the page to complete your disclosure.
Include the following information on the form
Meeting Name: 2017 KCACS Annual Scientific Meeting
Dates/Location: Friday, November 3, 2017 Lehigh Valley Hospital - Cedar Crest, Allentown, PA
Speaker Disclosure of Financial Relationships FORM
The Keystone Chapter of the American College of Surgeons (“KCACS”) wishes to place on its website, www.keystonesurgeons.org ("the website") professional medical educational material provided inte the 2017 Educational Program of the 2017 KCACS Annual Scientific Meeting. My Presentation will be made available to KCACS members and meeting attendees in satisfaction of their CME requirements and/or for general educational professional purposes. KCACS is taking that action for primarily educational purposes and, in particular, to promote broader understanding among pathologists of the subject matter of the Presentation. The Presentation will remain on the website for as long as three years but KCACS may remove the Presentation from the website at any earlier time in its sole discretion.
I understand that I will receive no compensation from KCACS for any use of the Presentation or an Altered Presentation (as defined in the following paragraph). I agree that allowing KCACS to post the Presentation or Altered Presentation provides professional benefits to me. For good and valuable consideration and intending to be legally bound, I enter into this Agreement.
By signing below. I hereby authorize the usage of the Presentation described herein and agrees that KCACS’s usage shall not be a violation of my ownership interests, including any copyright I hold, in the Presentation. I further grant permission for KCACS and any person or entity authorized by it: (i) to edit or alter the Presentation (any such edited or altered Presentation is referred to in this Agreement as an “Altered Presentation”), so long as doing so does not adversely or substantially affect the professional content; (ii) to distribute, broadcast, publish and/or transmit all or any portion of the Presentation or an Altered Presentation on its website for the purposes described above; and (iii) to use his/her name, likeness and biographical material in connection with any of the foregoing, all to the extent and in such fashion as they deem necessary or desirable to accomplish the purposes described in the first paragraph of this Agreement.
I represent that I am the owner of the copyright (solely or jointly) and has the right to permit use of the work by KCACS. I further represent that to the extent that the Presentation uses any third party material in a manner that requires agreement from such third party holder to that use, I have obtained such agreement.
I hereby releases KCACS, it’s individual members, and those members' home institutions from any claims or liability regarding any use that may be made of the Presentation or an Altered Presentation that is authorized by this Agreement.
I have read, understand, and accept the conditions of this agreement.
I hereby give the Keystone Chapter of the American College of Surgeons (KCACS) the right and permission to copyright and/or use, publish, and reuse and republish photographic pictures or portraits made of me, with or without my name, in connection with the above-identified subject, through any media and for whatever lawful purpose the company chooses in perpetuity.
I hereby release, discharge and agree to save harmless the KCACS, their representatives, employees, or any person or persons, corporations, acting under the permission of the company, including any firm publishing or distributing the finished product, even though the finished product may be blurred, altered, distorted or used in composite form, either intentionally or otherwise.
I hereby waive any right to approve the finished photograph or any copy that might be used in conjunction with the finished photograph.
I hereby warrant that I am over 21 years of age, and am competent to contract in my own name, insofar as the above is concerned.
I have read the foregoing release, authorization and agreement before affixing my signature below, and warrant that I fully understand the contents thereof: