1. Healthcare

PA I D
Charlotte, NC
Permit No. 2773
NON-PROFIT ORG
US Postage
Charlotte AHEC and The Department of Medicine of the
University of North Carolina at Chapel Hill School of Medicine Present:
Course Description
The 39th Annual Internal Medicine Conference
will provide an update on the most useful
recent developments in the diagnosis and
management of specific medical disorders
encountered by primary care physicians and
practicing specialists.
39TH ANNUAL
INTERNAL MEDICINE
CONFERENCE
Conference Features Include
➲ Panel discussions organized to address
questions and comments from participants
about important issues in the practice of
internal medicine.
➲ A program format which invites interaction
between faculty and participants.
RETURN SERVICE REQUESTED
Charlotte AHEC
Post Office Box 32861
Charlotte, NC 28232-2861
CONFERENCE INFORMATION
March 18-20, 2015
Jointly sponsored by The School of Medicine of
The University of North Carolina at Chapel Hill and Charlotte AHEC
Offered at
The William and Ida Friday Center for Continuing Education
Chapel Hill, North Carolina
➲ Participation of faculty and Chiefs from
the Divisions of the UNC Department of
Medicine.
➲ Guest faculty from other Universities and
Departments at UNC School of Medicine.
➲ Mini Symposium on Screening.
➲ An interdisciplinary approach to medical
practice.
➲ Optional “Meet the Professor” Discussion
Sessions. Participants will have an
opportunity to talk informally with UNC
Department of Medicine faculty and discuss
recent developments within a subspecialty,
and specific cases.
➲ Radiology Unknowns – Participants will
have an opportunity to study clinical cases
by X-ray and/or narrative description and
to make a diagnosis.
➲ Spouses and guests are also encouraged to
attend the reception at the Friday Center on
Thursday, March 19, 2015. This reception
will feature the Musical Classical Trio and
hors d’oeuvres!
Target Audience
This conference is designed for internists,
family physicians, generalists, and other health
care providers working in an adult primary
care setting.
Educational Objectives
The information presented at this educational
activity should improve your ability to:
➲ Discuss the diagnostic procedures for
common conditions seen by primary care
providers with focus on the sensitivity,
specificity and positive and negative
predictive values of the diagnostic procedure
➲ Analyze different therapeutics for common
conditions seen by primary care clinicians
➲ Assess results of recent clinical trials relevant
to health promotion and screening
Accreditation Statement
This activity has been planned and
implemented in accordance with the
accreditation requirements and policies of the
Accreditation Council for Continuing Medical
Education (ACCME) through the joint
providership of Carolinas HealthCare System/
Charlotte AHEC and The School of Medicine of
The University of North Carolina at Chapel Hill.
The Carolinas HealthCare System/Charlotte
AHEC is accredited by the ACCME to provide
continuning medical education for physicians.
Credit Designation Statement
The Carolinas HealthCare System/Charlotte
AHEC designates this Live Activity for a
maximum of 22 AMA PRA Category 1
Credit(s)™. Physicians should claim only the
credit commensurate with the extent of their
participation in this activity.
Wednesday, March 18 – 8.0
Thursday, March 19 – 8.25
Friday, March 20 – 5.75
The Charlotte Area Health Education Center
(AHEC) designates this continuing education
program as fulfilling the requirement for 2.2
Continuing Education Units (CEUs),
representing 22.0 Contact Hours.
AAFP Credit
Application for CME credit has been filed with
the American Academy of Family Physicians.
Determination of credit is pending.
Policy on Faculty and Sponsor
Disclosure
The Carolinas HealthCare System/Charlotte
AHEC adheres to the ACCME Standards
regarding industry support of continuing
medical education. Disclosure of faculty and
commercial support relationships, if any, will
be made known at the activity.
Conference Location
The conference will be held at the William and
Ida Friday Center for Continuing
Education, (100 Friday Center Drive,
Chapel Hill, NC 27599) located approximately
three miles east of the UNC-Chapel Hill
campus on Friday Center Drive, just off HWY
54 East. If you will be traveling I-40, you will
need to take Exit 273-A from Raleigh or 273
from Greensboro. Participants may be reached
during the conference at 919-962-3009.
Although every effort is made to provide a
comfortable temperature in the meeting room,
it is difficult to find a temperature that is
comfortable for everyone. Please bring a light
jacket or sweater in case the room is too cool
for your comfort.
WiFi access and electrical outlets will be
available.
Registration
Registration will be limited to 400
participants due to room capacity. Please see
www.charlotteahec.org regarding availability
of walk-in registrations.
Seats will be available in the main lecture hall
for all registrants. However, a satellite
conference room with audio/video feed will
also be available for those who prefer more
room to spread out, desks, and to sit where
food and drink are allowed.
Registration may be by fax, mail, or online.
The registration fees include educational credit,
course materials, breakfast, lunch, and breaks
for all three days, and the Thursday night
reception. All registrants must complete the
attached registration form or the similar form
online at www.charlotteahec.org.
Registrations will not be processed unless
accompanied by full payment (check, Visa,
MasterCard, Discover or American Express).
You may register by 1) faxing your form with
credit card information to 704-512-6561,
2) mailing your form with check or credit card
information to the address on the registration
form, or 3) submitting your registration
information online. Checks accompanying
registrations should be made payable to
Charlotte AHEC.
Online registration is available at
www.charlotteahec.org
For questions about registration, please go to
our website, www.charlotteahec.org, or call
Jessica Dietrich, Charlotte AHEC 704-512-6519.
When your registration is processed, you will
be emailed a confirmation.
Cancellation Policy
If you cancel more than 2-weeks in advance
there is a $25 cancellation fee. Participants that
are registered for the program and cancel
between 2 weeks and up to 48 hours prior to the
program will receive a 70% refund. No refunds
will be given for individuals who cancel less
than 48-hours prior to the program. No transfers
or refunds will be given for no-shows.
Substitutes are welcome (please notify us in
advance of the program). Cancellations must be
made in writing (fax, mail, or email).
Accommodations
Please contact the hotels directly to make
reservations and identify yourself as an
attendee at the 39th Annual Internal Medicine
Conference. A block of rooms has been
reserved at the following hotels:
ALOFT, located 1.2 miles from the Friday Center,
at a special rate of $119 + tax per night. Please
call 1-800-228-3000 to make your reservation.
This room block expires on February 17, 2015.
Courtyard by Marriott, located 0.3 miles from
the Friday Center, at a special rate of $127+ tax
per night. Please call 1-800-321-2211 or
919-883-0700 to make your reservation. This
room block will expire on February 17, 2015.
Sheraton Chapel Hill Hotel, located 4.8 miles
from the Friday Center, at a special rate of $111
+ tax per night. Please call 1-800-325-3535 or
919-969-2174 to make your reservation. This
hotel has a complimentary shuttle service to the
Friday Center. This room block expires on
February 15, 2015.
Please check the Chapel Hill/Orange County
Visitor’s Bureau website at http://www.
chovb.org for more information on hotels,
transportation and restaurants in the area.
NEPHROLOGY AND HYPERTENSION
8:35-9:15
9:15-9:55
9:55-10:15
10:15-10:30
Introduction
Gerald A. Hladik, MD
Role of the Primary Care Physician in the
Management of Patients with Chronic
Kidney Disease
Gerald A. Hladik, MD
Dialysis is not for Everyone: New Data for
Deciding with Older Patients
Alvin H. Moss, MD
OPEN PANEL DISCUSSION:
Nephrology and Hypertension
Audience Participation
Gerald A. Hladik, MD
Alvin H. Moss, MD
BREAK
3:55-4:15
10:35-11:10
11:10-11:30
11:30-11:55
11:55-l2:15
12:15-1:00
1:00-1:30
1:30-2:05
2:05-2:10
Introduction
Joanne M. Jordan, MD, MPH
The Shoulder: from Table to Bedside
Kenneth O’Rourke, MD
Update on Angioedema
Edwin Kim, MD, MS
An Approach to Muscle Weakness and Pain
Jennifer L. Rogers, MD
OPEN PANEL DISCUSSION:
Rheumatology, Allergy, and Immunology
Audience Participation
Joanne M. Jordan, MD, MPH, moderator
Edwin Kim, MD, MS
Kenneth O’Rourke, MD
Jennifer L. Rogers, MD
LUNCH: Trillium Room
OPTIONAL: “Meet the Professor”
Question and Answer Sessions:
Nephrology; Hypertension; Rheumatology,
Allergy, and Immunology; General Medicine
and Clinical Epidemiology; and
Gastroenterology and Hepatology
The Nusiasance of Snoring, but the
Opportunity of a Lifetime: Update on OSA
Bradley V. Vaughn, MD
Questions from the Audience
GENERAL MEDICINE & CLINICAL EPIDEMIOLOGY
Mini Symposium on Screening
2:10-2:15
2:15-2:40
2:40-3:10
3:10-3:35
Introduction
Daniel Jonas, MD, MPH
Screening, Behavioral Counseling, and
Medications for Unhealthy Alcohol use
Daniel Jonas, MD, MPH
Appropriate Implementation of Lung Cancer
Screening Guidelines
Daniel S. Reuland, MD, MPH
Should We Screen for Pre-Diabetes?
Thomas C. Keyserling, MD, MPH
11:00-11:20
11:20-11:45
GASTROENTEROLOGY AND HEPATOLOGY
4:15-4:20
4:20-4:40
4:40-5:05
5:05-5:30
5:30-5:55
5:55-6:15
RHEUMATOLOGY, ALLERGY, AND IMMUNOLOGY
10:30-10:35
OPEN PANEL DISCUSSION:
General Medicine and Clinical Epidemiology
Audience Participation
Daniel Jonas, MD, MPH, Moderator
Thomas C. Keysrling, MD, MPH
Daniel S. Reuland, MD, MPH
BREAK
Introduction
Ryan D. Madanick, MD
GERD in the PPI Era: Management Issues
in Primary Care
Ryan D. Madanick, MD
Screening for Colorectal Cancer: Will Current
Practices Be Changing Soon?
Sarah K. McGill, MD, MSc
Working Through Abnormal Liver Tests:
A Rational Approach
A. Sidney Barritt IV, MD, MSCR
Treating Hepatitis C in 2015:
The Future has Arrived
Jama M. Darling, MD
OPEN PANEL DISCUSSION:
Gastroenterology and Hepatology
Audience Participation
Ryan D. Madanick, MD Moderator
A. Sidney Barritt, IV, MD, MSCR
Jama M. Darling, MD
Sarah K. McGill, MD, MSc
THURSDAY, MARCH 19, 2015
7:30-8:00 AM
Registration and Continental Breakfast
8:00-8:05
Introductions
Myron S. Cohen, MD
Emerging Infectious Diseases (MERS-CoV,
novel influenza viruses, Ebola):
Focus on Ebola Preparedness
David J. Weber, MD, MPH
The Growing Threat of Multiple Drug
Resistant Organism (MDROs): Do New
Anti-Infectives Combat This Threat or Are
They Just Me Too Drugs
Jonathan Juliano, MD, MPH
Management of Immunocompromised
Patients: Key Issues for Primary Care
Providers
David van Duin, MD, PhD
OPEN PANEL DISCUSSION
Infectious Diseases
Audience Participation
Myron S. Cohen, MD, Moderator
David van Duin, MD, PhD
Jonathan Juliano, MD, MPH
David J. Weber, MD, MPH
BREAK
8:05-8:35
8:35-9:00
9:00-9:25
9:25-9:40
9:40-9:55
11:45-12:30
12:30-1:00
1:00-1:30
1:30-1:35
1:35-1:40
3:35-3:50
Introduction
Jan Busby-Whitehead, MD
Alzheimer’s Disease and Related Dementias:
Practical Strategies to Address Changing
Behavioral Symptoms
Gregg A. Warshaw, MD
Update on Parkinson’s Disease
Nina M. Browner, MD
Update on Code Status: Discussion for the
Primary Care Clinician
Gary S. Winzelberg, MD, MPH
OPEN PANEL DISCUSSION:
Geriatrics
Audience Participation
Jan Busby-Whitehead, MD, Moderator
Nina M. Browner, MD
Gregg A. Warshaw, MD
Gary S. Winzelberg, MD, MPH
BREAK
3:25-3:50
BREAK
HEMATOLOGY/ONCOLOGY
3:50-3:55
Introduction
Thomas C. Shea, MD
Management of Indolent Non-Hodgkin
Lymphoma
Steven I. Park, MD
Chronic Leukemias: What Generalists
Need to Know
Matthew C. Foster, MD
Determining Monoclonal Gammopathies
of Clinical Significance
Peter M. Voorhees, MD
Myeloproliferative Neoplasms: Recognition,
Diagnosis, and Complications
Brandi N. Reeves, MD
OPEN PANEL DISCUSSION
Hematology/ Oncology
Audience Participation
Thomas C. Shea, MD, Moderator
Matthew C. Foster, MD
Steven I. Park, MD
Brandi N. Reeves, MD
Peter M. Voorhees, MD
Reception and Entertainment with
Musical Classical Trio at the Friday Center
(Guests Welcome)
1:40-2:20
2:20-2:50
2:50-3:15
3:15-3:35
INFECTIOUS DISEASES
10:00-10:20
10:20-10:40
10:40-11:00
Introduction
John B. Buse, MD, PhD
Diabetes Medication Update
John B. Buse, MD, PhD
Diabetes Technology Update
Laura A. Young, MD, PhD
Diabetes Vignettes from the Wards
Elizabeth H. Harris, MD
FRIDAY, MARCH 20, 2015
7:30-8:00 AM
3:55-4:20
4:20-4:45
4:45-5:15
5:15-5:40
5:40-6:00
6:00-7:30
Guest Faculty
Registration and Continental Breakfast
Alvin H. Moss, MD - Professor of Medicine, Sections of
Nephrology and Supportive Care; Director, WVU Center
for Health Ethics and Law, West Virginia University
Kenneth O’Rourke, MD - Professor of Medicine; Director,
Rheumatology Fellowship Training Program,
Wake Forest School of Medicine
Gregg A. Warshaw, MD - Martha Betty Semmons
Professor of Geriatric Medicine, Geriatric Medicine
Program, College of Medicine, University of Cincinnati
CARDIOLOGY
8:00-8:05
8:05-8:30
8:30-8:55
8:55-9:20
9:20-9:45
9:45-10:05
GERIATRICS
ENDOCRINOLOGY
9:55-10:00
Osteoporosis Pharmacopeia: Start, Stop
or Change?
Janet Rubin, MD
OPEN PANEL DISCUSSION
Endocrinology
Audience Participation
John B. Buse, MD, PhD, Moderator
Elizabeth H. Harris, MD
Janet Rubin, MD
Laura A. Young, MD, PhD
Lunch-Trillium Room
OPTIONAL: “Meet the Professor”
Questions and Answer Sessions:
Infectious Diseases, Endocrinology, Diabetes,
Geriatrics, and Hematology/Oncology
(various locations)
Update on Medical Management
of Bipolar Disorder
Kenan Penaskovic, MD
Questions from the Audience
10:05-10:20
10:20-10:50
10:50-10:55
10:55-11:20
11:20-11:25
11:25-12:00
12:00-12:30
12:30-1:00
Introduction
George A. Stouffer, MD
Pulmonary Hypertension: The WHO and
What in 2015
Lisa J. Rose-Jones, MD
The 3 Most Important Cardiovascular Trials
from the Last Year for Primary Care Clinicians
Cody S. Deen, MD
Transcatheter Aortic Valve Replacement
(TAVR): Where are we now?
John P. Vavalle, MD, MHS
Hypertrophic Obstructive Cardiomyopathy
and Alcohol Septal Ablation
Michael Yeung, MD
OPEN PANEL DISCUSSION
Cardiology
Audience Participation
George A. Stouffer, MD, Moderator
Cody S. Deen, MD
Lisa J. Rose-Jones, MD
John P. Vavalle, MD, MHS
Michael Yeung, MD
BREAK
Psoriasis: from Bench to Bedside
Puneet S. Jolly, MD, PhD
Questions from the Audience
Late Breaking Presentation
(will address timely medical topic/research findings
reported or published in early 2015)
Questions from the Audience
LUNCH-Trillium Room
OPTIONAL: “Meet the Professor”
Questions from the Audience Sessions:
Cardiology and Pulmonary and Critical
Care Medicine (various locations)
Review of Radiology Unknowns
Joseph M. Stavas, MD
PULMONARY AND CRITICAL CARE MEDICINE
1:00-1:05
1:05-1:35
1:35-2:05
2:05-2:35
2:35-2:50
2:50
Introduction
Shannon S. Carson, MD
COPD: New Approaches and Therapies
James F. Donohue, MD
Asthma: New Therapies and Differentiating
Therapy from COPD
Stephen L. Tilley, MD
Pulmonary Rehabilitation: Benefits and
selection of patients
Ashley Henderson, MD
OPEN PANEL DISCUSSION:
Pulmonary and Critical Care Medicine
Audience Participation
Shannon S. Carson, MD, Moderator
James F. Donohue, MD
Ashley Henderson, MD
Stephen L. Tilley, MD
Conference Adjourns until March 30, 2016
UNC Department of Medicine Faculty
CONFERENCE DIRECTOR
Romulo E. Colindres, MD, MSPH - Professor of Medicine,
Division of Nephrology & Hypertension
CONFERENCE CO–DIRECTORS
Marco A. Alemán, MD - Professor of Medicine, Division
of General Medicine & Clinical Epidemiology
Thomas C. Keyserling, MD, MPH - Professor of Medicine,
Division of General Medicine & Clinical Epidemiology
A. Sidney Barritt, IV, MD, MSCR - Assistant Professor of
Medicine, Division of Gastroenterology & Hepatology
Jan Busby-Whitehead, MD - Professor of Medicine;
Chief, Division of Geriatric Medicine; Director, Center for
Aging and Health
John B. Buse, MD, PhD, CDE - Verne S. Caviness
Distinguished Professor of Medicine; Chief,
Division of Endocrinology
Shannon S. Carson, MD - Professor of Medicine;
Chief, Division of Pulmonary & Critical Care Medicine
Myron S. Cohen, MD - Yeargan-Bate Eminent Professor
of Medicine, Microbiology, and Immunology; Chief,
Division of Infectious Diseases; Associate Vice-Chancellor
for Global Health, UNC Institute for Global Health and
Infectious Diseases
Jama M. Darling, MD - Assistant Professor of Medicine,
Division of Gastroenterology and Hepatology
Cody S. Deen, MD - Assistant Professor of Medicine,
Division of Cardiology
James F. Donohue, MD - Professor of Medicine, Division
of Pulmonary Diseases & Critical Care Medicine
Matthew C. Foster, MD - Assistant Professor of Medicine,
Division of Hematology/Oncology
Elizabeth H. Harris, MD - Assistant Professor of Medicine,
Division of Endocrinology
Ashley Henderson, MD - Associate Professor of Medicine,
Division of Pulmonary Diseases & Critical Care Medicine
Gerald A. Hladik, MD - Doc. J. Thurston Distinguished
Professor of Medicine, Division of Nephrology &
Hypertension
Joanne M. Jordan, MD, MPH - Joseph P. Archie, Jr.
Eminent Professor of Medicine; Chief, Division of
Rheumatology, Allergy & Immunology; Director,
Thurston Arthritis Research Center
Daniel Jonas, MD, MPH - Associate Professor & Section
Chief for Research, Division of General Medicine &
Clinical Epidemiology; Co-Director, RTI-UNC
Evidence-based Practice Center
Jonathan Juliano, MD, MPH - Assistant Professor of
Medicine, Division of Infectious Diseases; Director,
Anti-Infective Stewardship
Edwin Kim, MD, MS - Assistant Professor of Medicine,
Division of Rheumatology, Allergy & Immunology
Ryan D. Madanick, MD - Assistant Professor of Medicine,
Division of Gastroenterology & Hepatology
Sarah K. McGill, MD, MSc - Assistant Professor of Medicine,
Division of Gastroenterology and Hepatology
Steven I. Park, MD - Assistant Professor of Medicine,
Division of Hematology/Oncology
Brandi N. Reeves, MD - Clinical Fellow, Division of
Hematology/Oncology
Daniel S. Reuland, MD, MPH - Associate Professor of
Medicine, Division of General Medicine & Clinical
Epidemiology
Jennifer L. Rogers, MD - Assistant Professor of Medicine,
Division of Rheumatology, Allergy & Immunology;
Co-Director, Adult Lupus Clinic
Lisa J. Rose-Jones, MD - Assistant Professor of Medicine,
Division of Cardiology
Janet Rubin, MD - Professor of Medicine, Division of
Endocrinology
Thomas C. Shea, MD - Professor of Medicine, Division of
Hematology/Oncology; Director, Bone Marrow Transplant
Program
George A. Stouffer, MD - Henry A. Foscue Distinguished
Professor of Medicine; Chief, Division of Cardiology; Director,
Interventional Cardiology
Stephen L. Tilley, MD - Associate Professory of Medicine,
Division of Pulmonary Diseases & Critical Care Medicine
David van Duin, MD, PhD - Associate Professor of Medicine,
Division of Infectious Diseases; Director,
Immunocompromised Host Section
John P. Vavalle, MD, MHS - Assistant Professor of Medicine,
Division of Cardiology
Peter M. Voorhees, MD - Associate Professor of Medicine,
Division of Hematology/Oncology
David J. Weber, MD, MPH - Professor of Medicine,
Pediatrics, and Epidemiology, Schools of Medicine and Public
Health; Associate Chief of Staff, UNC Health Care; Medical
Director, Hospital Epidemiology & Occupational Health
Gary S. Winzelberg, MD, MPH - Associate Professor of
Medicine, Division of Geriatrics
Michael Yeung, MD - Assistant Professor of Medicine,
Division of Cardiology
Laura A. Young, MD, PhD - Assistant Professor of Medicine,
Division of Endocrinology
The 39th Annual Internal Medicine Conference
March 18-20, 2015
Event # 44907
Please Print Legibly
Last Name: ____________________________________ First Name: __________________
MI: _________
Mailing Address: Please check appropriate box: ❑ Home ❑ Business
________________________________________________________________________________________________
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City: ______________________________________
State: _________________
Zip Code:
Phone: _________________________________________
E-mail: __________________________________________________________________________________________
Sex: ❑ Male
REGISTRATION FORM
39TH ANNUAL INTERNAL MEDICINE CONFERENCE AGENDA
Thomas C. Keyserling, MD, MPH
Marco A. Alemán, MD
Conference Co-Directors
8:30-8:35
3:35-3:55
Registration and Continental Breakfast
Welcome and Announcements
Romulo E. Colindres, MD, MSPH
Conference Director
CONFERENCE FACULTY
WEDNESDAY, MARCH 18, 2015
7:30-8:20 AM
8:20-8:30
❑ Female
Degree:
Last 4 Digits of Social Security Number: _______________
Employer:
Specialty: _______________________________________
Please check all that apply:
❑ Fellow
❑ MD
❑ PhD
❑ NP
❑ PharmD
❑ Student
❑ Resident
❑ DO
❑ PA
❑ RN
❑ RPh
❑ Other
Disclaimer: By providing your email address and telephone number, you have granted permission for AHEC to contact you
via the numbers and address indicated. Would you like your name to be removed from our mailing list? ❑ Yes ❑ No
REGISTRATION
Please complete a separate registration form for each person. Registrations will not be processed unless accompanied
by full payment (check, or credit card). You may register by:
•
•
•
faxing your form, with complete credit card information, to 704-512-6561
completing on-line registration at: www.charlotteahec.org
mailing your form, along with a check or complete credit card information, to:
Charlotte AHEC Registrar
PO Box 32861
Charlotte, NC 28232-2861
REGISTRATION FEES (please mark applicable fee) Registration will be limited to 400 participants due to room
capacity, therefore, availability for walk-in registration will be dependent on participant numbers. Please see
www.charlotteahec.org regarding availability for walk-in registrations.
Faculty from other UNC Departments
Nina M. Browner, MD - Assistant Professor, Department
of Neurology
Puneet S. Jolly, MD, PhD - Assistant Professor, Department
of Dermatology
Kenan Penaskovic, MD - Assistant Professor, Department
of Psychiatry
Joseph M. Stavas, MD - Professor, Department of Radiology
Bradley V. Vaughan, MD - Professor, Department of
Neurology
❑ Total Conference $420.00
❑ UNC Faculty $75.00/Day
❑ $350.00/Two Day
❑ $200.00/One Day
SPECIAL ACTIVITIY – Thursday, March 19, 2015
❑ Reception at the Friday Center
______________________ # Attending Reception
Please indicate if you would like a vegetarian meal: ❑ Yes ❑ No
METHOD OF PAYMENT
❑ Check made payable to Charlotte AHEC enclosed
❑ Credit Card (Visa, Mastercard, Discover, AmEx)
Credit Card #: ____ ____ ____ ____ – ____ ____ ____ ____ – ____ ____ ____ ____ – ____ ____ ____ ____
Expiration Date ____ ____ / ____ ____
Signature of Cardholder
Americans with Disabilities Act: If you need any auxiliary aides or services identified in the Americans with Disabilities
Act in order to attend this activity, please contact Jessica Dietrich by telephone at 704-512-6519 or by email at
[email protected]. This request must be received 7 days prior to this activity.