Print final_T_logo_color.jpg Please fill in as much information as you can. If you do not have a healthcare professional to present the program USBJI will be happy to locate a presenter for you. Venue Preferred date(s) and time(s) Expected Number of Participants Session Venue Name Session * Live Session Webinar Session Videoconference Session Recorded Session Street Address Street Address Line 2 City Postal Code State/Province Organizer Name Prefix - None -Mrs.Ms.Mr.Dr. First Name * Middle Last Name * Name Suffix - None -, Jr., Sr. II III IV V VI VII Position Organization Name Address type WorkHomeOther Street Address Street Address Line 2 City State/Province Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo, Republic Of TheCongo, The Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSAINT BARTHéLEMYSaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSerbia and MontenegroSeychellesSierra LeoneSingaporeSint Maarten (Dutch Part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Phone Number * Phone Extension Phone Location BillingHomeMainOtherWork Email * Do you have a healthcare professional to lead the presentation? * Yes, s/he is…No, please provide one. Presenter Name Prefix - None -Mrs.Ms.Mr.Dr. First Name Middle Last Name Name Suffix - None -, Jr., Sr. II III IV V VI VII Credentials May include academic credentials (e.g. MD, PhD), certifications (e.g. PMP, CFP), affiliations (AAO SJ), and the like. Job Title Organization Name Presenter Address Street Address Street Address Line 2 City State/Province Postal Code Phone Number Phone Extension Email Session Session Location Name * Address Country - None -United States Address 1 Address 2 City State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code Organizer Contact Information Name * Email * Phone * Best number to reach you at. Address Country - None -United States Address 1 Address 2 City State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code Position Professional Organization List the professional organizations you are a member of. Presenter Contact InformationUSBJI will provide a HealthCare Professional to present if you do not have one. Name USBJI will provide a HealthCare Professional to present if you do not have one. Credentials Email Phone Best number to reach you at. Address Country - None -United States Address 1 Address 2 City State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code Position Promoting the session(s) Promo Flyer Template Yes, we would like to use No, we will make up our own flyer Color flyer (8 1/2 x 11, one-sided) with details on session, including date, time, place, and speaker, that can be reproduced. The flyer can also be printed up as a poster. Bookmarks Quantity: - None -253035404550556065707580859095100105110115120125130135140145150155160165170175180185190195200205210215220225230235240245250255260265270275280285290295300305310315320325330335340345350355360365370375380385390395400405410415420425430435440445450455460465470475480485490495500 With date, time, place, and speaker details. The USBJI will send you quantities of the following handout materials based on the expected number of participants. Booklet/National Resource List/Bibliography A Fit to a T booklet accompanies the presentation and is for distribution to session participants along with a Self Risk Assessment Questionnaire, Resource List, and Bibliography. The NIH Osteoporosis and Related Bone Diseases - National Resource Center (NRC) will send you copies of the Surgeon General's report on Bone Health and Osteoporosis, a condensed summary for the lay public. Disclaimer: These books may not have been approved by healthcare professionals and the information they offer should not be used without consulting your own physician. To request copies of People’s Piece “What It Means to You,” indicate the number next to each respective language below: English Spanish Chinese Leave this field blank