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	<title>2026 NYACP Scientific Meeting Registration | New York Chapter of the American College of Physicians</title>


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			<p class="form-instructions"><h1><span class="title"><img alt="" src="https://www.nyacp.org/images/Clip%20Art%2C%20Stock%20Photos%2C%20Icons/save%20the%20date(1).jpg" style="width: 100px; margin-left: 10px; margin-right: 10px; float: right; height: 71px;" /></span><strong><span class="subtitle">NYACP&#39;s Annual Scientific Meeting<br />
Registration Form</span></strong></h1>

<div condensed="" id="i4acontent_area_outer" roboto="" style="box-sizing: border-box; color: rgb(33, 37, 41); font-family: ">
<div id="i4acontent_area" style="box-sizing: border-box;">
<p style="box-sizing: border-box; margin: 0px 0px 10px; font-weight: 700; line-height: 20.4px; font-size: 17px; padding: 0px; color: rgb(112, 39, 133);"><span style="color:#000000;">Crowne Plaza/Desmond Hotel<br />
660 Albany Shaker Road<br />
Albany, NY&nbsp; 12211</span></p>
</div>
</div>

<p><b>Saturday, October 24, 2026</b></p>
</p>
		

	<form action="index.cfm?id=542&popup=false" method="POST" id="iform" name="iform" enctype="multipart/form-data">
		
		<input type="hidden" id="num_questions" name="num_questions" value="16">
		<input type="hidden" name="form_id" value="542">
		<input type="hidden" name="report_id" value="">
		<input type="hidden" name="AllowedUploads" value="doc,docx,docm,dotx,dotm,eps,epub,htm,ics,lit,mobi,msg,pdf,potx,potm,ppam,ppsx,ppsm,pps,ppt,pptm,pptx,pub,txt,xls,zip,xlsx,xlsm,xltx,xltm,xlsb,xlam,vcf,sgf,gif,jpg,jpeg,jpe,png">
		
		
<script>
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			$('#formsPayment').css('max-width', '100%');
		
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	function limitText(limitField, limitCount, limitNum) {
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	var validForm = false;
	var sent = 0;
	
	// Thibault 2/11/06 added init function called at page load, plus validation that required fields are completed before submit.  should help with problems with the back button and credit cards,  issue 30102
	function init() {
		frm = document.iform;

		
	}

	window.onload = new Function("init()"); //set init function to run at page load

	function lcase(mystring)  {
		return mystring.toLowerCase()
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		fld_ss_form_testid.value = 1;
		if (mainV) {
			
				iForm.submit();
			
		}
	}

	function validateFrm() {
		if(!sent) sent = 0;  //make sure we have this!
		if (!validForm) validForm = false;
		arrReqMissing = new Array();
		
			
			var jsDesc = " ACP Number ";
			
			
			var jsDesc = " First Name";
			
				obj = document.iform.response_2;
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			var jsDesc = " Last Name ";
			
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			var jsDesc = " Cred. ";
			
			
			var jsDesc = "Mailing Address";
			
				obj = document.iform.response_5;
				val = "";
				
				val = obj.value;
				if (obj.value == "") {
					arrReqMissing[arrReqMissing.length] = jsDesc;
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			var jsDesc = "City";
			
				obj = document.iform.response_6;
				val = "";
				
				val = obj.value;
				if (obj.value == "") {
					arrReqMissing[arrReqMissing.length] = jsDesc;
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			var jsDesc = "State";
			
				obj = document.iform.response_7;
				val = "";
				
			
			var jsDesc = "Zip ";
			
				obj = document.iform.response_8;
				val = "";
				
				val = obj.value;
				if (obj.value == "") {
					arrReqMissing[arrReqMissing.length] = jsDesc;
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			var jsDesc = "Phone";
			
				obj = document.iform.response_9;
				val = "";
				
				val = obj.value;
				if (obj.value == "") {
					arrReqMissing[arrReqMissing.length] = jsDesc;
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			var jsDesc = "Email";
			
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				val = "";
				
				val = obj.value;
				if (obj.value == "") {
					arrReqMissing[arrReqMissing.length] = jsDesc;
				}
				
			
			var jsDesc = "How Did You Hear About This Meeting?";
			
			
			var jsDesc = "Please note any dietary restrictions ";
			
			
			var jsDesc = "Check here if you are disabled and require assistance.  We encourage participation by all individuals. \n\r\nAdvance notification is essential in order for us to serve you better. Please notify the NY Chapter in writing at least 30 days before the meeting. We’ll be glad to help!";
			
			
			var jsDesc = "NYACP Member Rates";
			
			
			var jsDesc = "NYACP Non-Member Rates";
			
			
			var jsDesc = "Additional Registrations - Payment link will follow.";
			
			
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			errStr = "";
			for(i=0; i<arrReqMissing.length; i++) {
				errStr += arrReqMissing[i] + "<br>";
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			swal({
	  			title: 'Missing required fields',
	  			html: true,
	  			text: errStr,
	  			animation: 'slide-from-top',
	  			type: 'info',
	  			confirmButtonText: 'Ok',
	  			confirmButtonColor: '#337ab7'
	  		});
			return false;
		}

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		 			swal({
			  			title: 'Maximum allowable length',
			  			html: true,
			  			text: "One or more field responses exceeds the maximum allowable length of 2147483647 characters. Please adjust your responses and re-submit.",
			  			animation: 'slide-from-top',
			  			type: 'info',
			  			confirmButtonText: 'Ok',
			  			confirmButtonColor: '#337ab7'
			  		});
		 			return false;
		 		}
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		if (sent == 1) {
	          swal({
	  			title: 'Processing..',
	  			html: true,
	  			text: "Your request is processing. Please do not click Submit more than once.",
	  			animation: 'slide-from-top',
	  			type: 'info',
	  			confirmButtonText: 'Ok',
	  			confirmButtonColor: '#337ab7'
	  		  });
	          return false;
	    }
		
			bOK = true;
		
		if (bOK) {
			var btn = $('#submitBtn');
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			sent = 1;
			validForm = true;
			return true;
		}
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			return false;
		}
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	   var IsNumber=true;
	   var Char;

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	function setButtonVal(el, itemID, price) {
		// first set the price attribute on the element
		el.price = price;
		// now set the value of a hidden field for the associated radio button
		document.getElementById(itemID).price = price;
		document.getElementById(itemID).value = 1;
		// now call the calcTotalFix function to recaculate the total amount due
		calcTotalFix();
	}

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		var selectedPrice = 0;
		for(i=0; i < rads.length; i++) {
		  if(rads[i].checked == true){
		    selectedPrice = rads[i].getAttribute('price');
		  }
		}

		selectedPrice = parseFloat(selectedPrice);
		return selectedPrice;
	}

	function calcTotalFix() {
		var priceFields = $(".calculateTotal");
		// console.log('priceFields length: ' + priceFields.length);
		var updateTotal = 0; // initialize total before looping over array
		var processedRadioButtons = [];	/// reset array every time this function is called
		for (var i=0; i < priceFields.length; i++) {
			myFieldObj = priceFields[i];
			if (myFieldObj.value == '') { myFieldObj.value = 0; }
			fieldName = myFieldObj.name;
			value = myFieldObj.value;
			fieldID = myFieldObj.getAttribute('id');
			price = myFieldObj.getAttribute('price');

			// check to see if this is a radioVal by the item id
			if(fieldID != undefined){
				var nRadioVal = fieldID.indexOf("radioVal");
				if(nRadioVal > -1){
					fieldtype = 'radioval';
				} else {
					fieldtype = 'notradioval';
				}
			} else {
				fieldtype = 'nofieldid';
			}

			// if this is just an open price field, there is no notion of quantity times price, so the price to the value of the field
			if(fieldtype === 'radioval'){
				// radio price field - use "price" attribute since we have funky stuff in the "value" attribute that we can't parse easily
				arrNum = $.inArray(fieldName, processedRadioButtons);
				if(arrNum > -1) {
					// set price and calcualted value to zero for the rest of the checkboxes in this array because don't want to keep adding to price
					price = 0;
					calculatedValue = parseFloat(0);
				} else {
					price = getRadioButtonValForTotal(fieldName);
					calculatedValue = parseFloat(price);
					// add radio button field name to array of radio fields processed so we don't check again
					processedRadioButtons.push(fieldName);
				}
				// console.log('fieldName: ' + fieldName + ' / value: ' + value + ' fieldID: ' + fieldID + ' / price: ' + price + ' / calculatedValue: ' + calculatedValue);
			} else {
				if (price === undefined || price === null) {
				// check to see if it's a radio price field first
					// open price field - use "value" attribute
					if (!IsNumeric(value)) {
						//alert("Open Prices must be numbers only, no formatting is allowed.");
						swal({
				  			title: 'Numbers only',
				  			html: true,
				  			text: "Open Prices must be numbers only, no formatting is allowed.",
				  			animation: 'slide-from-top',
				  			type: 'info',
				  			confirmButtonText: 'Ok',
				  			confirmButtonColor: '#337ab7'
				  		});
						myFieldObj.value = 0;
						return;
					}
					calculatedValue = parseFloat(value);
					// console.log('fieldName: ' + fieldName + ' / value: ' + value + ' fieldID: ' + fieldID + ' / price: ' + price + ' / calculatedValue: ' + calculatedValue);
				} else {
					if (!IsNumeric(value)) {
						//alert("Price fields only allow numbers.");
						swal({
				  			title: 'Price fields',
				  			html: true,
				  			text: "Price fields only allow numbers.",
				  			animation: 'slide-from-top',
				  			type: 'info',
				  			confirmButtonText: 'Ok',
				  			confirmButtonColor: '#337ab7'
				  		});
						myFieldObj.value = 0;
						return;
					}
					myVal = parseFloat(value);
					// console.log('in parseint with 10 - fieldName: ' + fieldName + ' / value: ' + value + ' fieldID: ' + fieldID + ' / price: ' + price + ' / myVal: ' + myVal);
					calculatedValue = myVal * parseFloat(price);

				}
			}


			// console.log('Field id: ' + fieldID + ' / Fieldtype: ' + fieldtype + ' / Field name: ' + fieldName + ' / value: ' + value + ' / Price: ' + price + ' / Calculated Field Total: ' + calculatedValue);
			updateTotal = updateTotal + calculatedValue;
		}

		// update hidden total amount
		if (document.iform.hiddentotal) { document.iform.hiddentotal.value = updateTotal; }
		// console.log('The updateTotal is now: ' + updateTotal);
		
		
		// update total value with formatted amount
		if (typeof(formatCurrency) == "function") { document.iform.total.value = formatCurrency(updateTotal); }
		
		if ($('#ordertotal_work').length > 0) {
            $('#ordertotal_work').val(updateTotal.toFixed(2));
        }
        
        if ($('#pmt_method').length > 0) {
        	$('#pmt_method').val('');
        }
        $('.paymentProfileRadio').prop('checked', false);
        $('.card').removeClass('active');
        
		// need to update the cc_info tag fields...
		if (typeof(checkTotal) == "function") { checkTotal(); }
	}

	/* remove after confirming ok without it - 8/8/13 CJV */
	function calcTotal(myField){
		thisVal = myField.value;
		// alert(thisVal);
		if (thisVal == '') {
			thisVal = 0;
			myField.value = 0;
			}
			if (!IsNumeric(myField.value)) {
				//alert('Please enter only numbers or decimal points in a price field');
				swal({
		  			title: 'Price field',
		  			html: true,
		  			text: "Please enter only numbers or decimal points in a price field.",
		  			animation: 'slide-from-top',
		  			type: 'info',
		  			confirmButtonText: 'Ok',
		  			confirmButtonColor: '#337ab7'
		  		});
				myField.value = 0;
				thisVal = 0;
				}
				// get the current total
				var origTotal = document.iform.hiddentotal.value;
				// now backout the prior value from the total
				var priorTotal = origTotal - myField.priorval;
				if(priorTotal == ''){
					priorTotal = 0;
					}
				// add the open price to the total
				updateTotal = parseFloat(eval(priorTotal)) + parseFloat(eval(thisVal));
				// update hidden total amount
				document.iform.hiddentotal.value = updateTotal;
				
					
				// update total value with formatted amount
				document.iform.total.value = formatCurrency(updateTotal);
		checkTotal(); // need to update the cc_info tag fields...
	}
	/* */

	function setOpenPriceInput(thisField,thisPrice){
		if(thisPrice == ''){
			thisField.priorval = 0;
		} else {
			thisField.priorval = thisPrice;
		}
	}

	
		var div_bottom_moved = false;

		function addLoadEvent(func) {
 			var oldonload = window.onload;
  			if (typeof window.onload != 'function') {
    			window.onload = func;
  			}
  			else {
    			window.onload = function() {
      				if (oldonload) {
        				oldonload();
      				}
      				func();
    			}
  			}
 		}

		addLoadEvent(calcTotalFix);
	
</script>

	
<style>
.has-error {
	color: #f70404 !important;
}
.has-error input {
	border: 1px solid #f70404 !important;
}
</style>


<script>
	function checkInvalidCharacter(objName){
		var obj = document.iform[objName];
		var strFileName = obj.value.replace('C:\\fakepath\\','');
		iTemp = strFileName.indexOf(":");
		
		if (iTemp > -1) {
			swal({
	  			title: 'Invalid character',
	  			html: true,
	  			text: "Invalid character ':' found in file name. Please change the file name before attempting to upload this file.",
	  			animation: 'slide-from-top',
	  			type: 'info',
	  			confirmButtonText: 'Ok',
	  			confirmButtonColor: '#337ab7'
	  		});
			obj.value = '';
			return false;
		}
		else {
			iTemp = obj.value.indexOf(",");
			if (iTemp > -1) {
				swal({
		  			title: 'Invalid character',
		  			html: true,
		  			text: "Invalid character ',' found in file name. Please change the file name before attempting to upload this file.",
		  			animation: 'slide-from-top',
		  			type: 'info',
		  			confirmButtonText: 'Ok',
		  			confirmButtonColor: '#337ab7'
		  		});
				obj.value = '';
				return false;
			}
		}
	}
	function clearRadio(rd) {
		if (document.iform) {
			var v;
			var ln;
			var ev;
			submitted = 0;
			v = "document.iform." + rd + ".length";
			ln = eval(v);
			// This will ensure we uncheck if there is only 1 radio button..
			v = "document.iform." + rd + ".checked = false;";
			ev = eval(v);
			// Now loop through the list of radio buttons and uncheck them all
			for (i=0;i<ln;i++) {
				v = "document.iform." + rd + "[" + i + "].checked = false;";
				//console.log(v);
				ev = eval(v);
			}
			calcTotalFix();
		}
	}
</script>


<div class="form_layout_wrapper" style="max-width:947px;" >

	
			<!-- The inner div, for the sake of IE -->
			<div id="layout_form_item" style="clear:both;border:0px solid orange;margin:0 0 0px 0;padding:0;min-height:0px;">
		

		<div id="form-item-12926" class="layout form item outer row-1 item-12926 row_num-20 row_pos-20 rowlength-1 type-Text" style="clear:both;;position:relative;">

			<div class="inner">

				
							<b> ACP Number </b>
					

							<input type="text"
								
									id="response_1"
									name="response_1"
								
								
								 style="width:156px;"
								
									
										value=""
									
								
								class="form-control type-Text row-1 item-12926"
							><!-- input -->

							
				<input type="hidden" name="question_1" value="&lt;b&gt; ACP Number &lt;/b&gt;">
				<INPUT TYPE="hidden" NAME="response_1_question_id" VALUE="12926">
				<INPUT TYPE="hidden" NAME="question_type_1" value="Text">
				<INPUT TYPE="hidden" NAME="label_1" value="ACP Number">

				
			</div> <!-- /inner -->

		</div> <!-- /layout_form_item -->

		
				</div> <!-- /The inner div, for the sake of IE -->
			
			<!-- The inner div, for the sake of IE -->
			<div id="layout_form_item" style="clear:both;border:0px solid orange;margin:0 0 0px 0;padding:0;min-height:0px;">
		

		<div id="form-item-12927" class="layout form item outer row-2 item-12927 row_num-40 row_pos-20 rowlength-3 type-Text" style="clear:both;;position:relative;">

			<div class="inner">

				
							<b> First Name</b><span class="text-danger"> *</span>
					

							<input type="text"
								
									id="response_2"
									name="response_2"
								
								
								 style="width:260px;"
								
									
										value=""
									
								
								class="form-control type-Text row-2 item-12927"
							><!-- input -->

							
						<INPUT
							TYPE="hidden"
							NAME="response_2_required"
							VALUE="The field <b> First Name</b> is required. Please click your browser's back button and provide this value.">
					

				<input type="hidden" name="question_2" value="&lt;b&gt; First Name&lt;/b&gt;">
				<INPUT TYPE="hidden" NAME="response_2_question_id" VALUE="12927">
				<INPUT TYPE="hidden" NAME="question_type_2" value="Text">
				<INPUT TYPE="hidden" NAME="label_2" value="First Name">

				
			</div> <!-- /inner -->

		</div> <!-- /layout_form_item -->

		
		<div id="form-item-12928" class="layout form item outer row-3 item-12928 row_num-40 row_pos-40 rowlength-3 type-Text" style=";position:relative;">

			<div class="inner">

				
							<b> Last Name </b><span class="text-danger"> *</span>
					

							<input type="text"
								
									id="response_3"
									name="response_3"
								
								
								 style="width:156px;"
								
									
										value=""
									
								
								class="form-control type-Text row-3 item-12928"
							><!-- input -->

							
						<INPUT
							TYPE="hidden"
							NAME="response_3_required"
							VALUE="The field <b> Last Name </b> is required. Please click your browser's back button and provide this value.">
					

				<input type="hidden" name="question_3" value="&lt;b&gt; Last Name &lt;/b&gt;">
				<INPUT TYPE="hidden" NAME="response_3_question_id" VALUE="12928">
				<INPUT TYPE="hidden" NAME="question_type_3" value="Text">
				<INPUT TYPE="hidden" NAME="label_3" value="Last Name">

				
			</div> <!-- /inner -->

		</div> <!-- /layout_form_item -->

		
		<div id="form-item-12930" class="layout form item outer row-4 item-12930 row_num-40 row_pos-60 rowlength-3 type-Text" style=";position:relative;">

			<div class="inner">

				
							<b> Cred. </b>
					

							<input type="text"
								
									id="response_4"
									name="response_4"
								
								
								 style="width:80px;"
								
									
										value=""
									
								
								class="form-control type-Text row-4 item-12930"
							><!-- input -->

							
				<input type="hidden" name="question_4" value="&lt;b&gt; Cred. &lt;/b&gt;">
				<INPUT TYPE="hidden" NAME="response_4_question_id" VALUE="12930">
				<INPUT TYPE="hidden" NAME="question_type_4" value="Text">
				<INPUT TYPE="hidden" NAME="label_4" value="Cred.">

				
			</div> <!-- /inner -->

		</div> <!-- /layout_form_item -->

		
				</div> <!-- /The inner div, for the sake of IE -->
			
			<!-- The inner div, for the sake of IE -->
			<div id="layout_form_item" style="clear:both;border:0px solid orange;margin:0 0 0px 0;padding:0;min-height:0px;">
		

		<div id="form-item-12931" class="layout form item outer row-5 item-12931 row_num-60 row_pos-20 rowlength-1 type-Text" style="clear:both;;position:relative;">

			<div class="inner">

				
							<b>Mailing Address</b><span class="text-danger"> *</span>
					

							<input type="text"
								
									id="response_5"
									name="response_5"
								
								
								 style="width:510px;"
								
									
										value=""
									
								
								class="form-control type-Text row-5 item-12931"
							><!-- input -->

							
						<INPUT
							TYPE="hidden"
							NAME="response_5_required"
							VALUE="The field <b>Mailing Address</b> is required. Please click your browser's back button and provide this value.">
					

				<input type="hidden" name="question_5" value="&lt;b&gt;Mailing Address&lt;/b&gt;">
				<INPUT TYPE="hidden" NAME="response_5_question_id" VALUE="12931">
				<INPUT TYPE="hidden" NAME="question_type_5" value="Text">
				<INPUT TYPE="hidden" NAME="label_5" value="Address">

				
			</div> <!-- /inner -->

		</div> <!-- /layout_form_item -->

		
				</div> <!-- /The inner div, for the sake of IE -->
			
			<!-- The inner div, for the sake of IE -->
			<div id="layout_form_item" style="clear:both;border:0px solid orange;margin:0 0 0px 0;padding:0;min-height:0px;">
		

		<div id="form-item-12901" class="layout form item outer row-6 item-12901 row_num-80 row_pos-20 rowlength-3 type-Text" style="clear:both;;position:relative;">

			<div class="inner">

				
							<b>City</b><span class="text-danger"> *</span>
					

							<input type="text"
								
									id="response_6"
									name="response_6"
								
								
								 style="width:156px;"
								
									
										value=""
									
								
								class="form-control type-Text row-6 item-12901"
							><!-- input -->

							
						<INPUT
							TYPE="hidden"
							NAME="response_6_required"
							VALUE="The field <b>City</b> is required. Please click your browser's back button and provide this value.">
					

				<input type="hidden" name="question_6" value="&lt;b&gt;City&lt;/b&gt;">
				<INPUT TYPE="hidden" NAME="response_6_question_id" VALUE="12901">
				<INPUT TYPE="hidden" NAME="question_type_6" value="Text">
				<INPUT TYPE="hidden" NAME="label_6" value="City">

				
			</div> <!-- /inner -->

		</div> <!-- /layout_form_item -->

		
		<div id="form-item-12902" class="layout form item outer row-7 item-12902 row_num-80 row_pos-40 rowlength-3 type-StateSelect" style="max-width:33%;position:relative;">

			<div class="inner">

				
							<b>State</b><span class="text-danger"> *</span>
					

								<select
									id="response_7"
									name="response_7"
									
									
									class="form-control type-StateSelect row-7 item-12902"
									>
									
									
										<option value="AB" >AB</option>
									
										<option value="AK" >AK</option>
									
										<option value="AL" >AL</option>
									
										<option value="AR" >AR</option>
									
										<option value="AZ" >AZ</option>
									
										<option value="BC" >BC</option>
									
										<option value="CA" >CA</option>
									
										<option value="CO" >CO</option>
									
										<option value="CT" >CT</option>
									
										<option value="DC" >DC</option>
									
										<option value="DE" >DE</option>
									
										<option value="FL" >FL</option>
									
										<option value="GA" >GA</option>
									
										<option value="HI" >HI</option>
									
										<option value="IA" >IA</option>
									
										<option value="ID" >ID</option>
									
										<option value="IL" >IL</option>
									
										<option value="IN" >IN</option>
									
										<option value="KS" >KS</option>
									
										<option value="KY" >KY</option>
									
										<option value="LA" >LA</option>
									
										<option value="MA" >MA</option>
									
										<option value="MB" >MB</option>
									
										<option value="MD" >MD</option>
									
										<option value="ME" >ME</option>
									
										<option value="MI" >MI</option>
									
										<option value="MN" >MN</option>
									
										<option value="MO" >MO</option>
									
										<option value="MS" >MS</option>
									
										<option value="MT" >MT</option>
									
										<option value="NB" >NB</option>
									
										<option value="NC" >NC</option>
									
										<option value="ND" >ND</option>
									
										<option value="NE" >NE</option>
									
										<option value="NF" >NF</option>
									
										<option value="NH" >NH</option>
									
										<option value="NJ" >NJ</option>
									
										<option value="NM" >NM</option>
									
										<option value="NV" >NV</option>
									
										<option value="NY" >NY</option>
									
										<option value="OH" >OH</option>
									
										<option value="OK" >OK</option>
									
										<option value="ON" >ON</option>
									
										<option value="OR" >OR</option>
									
										<option value="PA" >PA</option>
									
										<option value="PE" >PE</option>
									
										<option value="PQ" >PQ</option>
									
										<option value="PR" >PR</option>
									
										<option value="RI" >RI</option>
									
										<option value="SC" >SC</option>
									
										<option value="SD" >SD</option>
									
										<option value="SK" >SK</option>
									
										<option value="TN" >TN</option>
									
										<option value="TX" >TX</option>
									
										<option value="UT" >UT</option>
									
										<option value="VA" >VA</option>
									
										<option value="VT" >VT</option>
									
										<option value="WA" >WA</option>
									
										<option value="WI" >WI</option>
									
										<option value="WV" >WV</option>
									
										<option value="WY" >WY</option>
									
								</select>
							
							
						<INPUT
							TYPE="hidden"
							NAME="response_7_required"
							VALUE="The field <b>State</b> is required. Please click your browser's back button and provide this value.">
					

				<input type="hidden" name="question_7" value="&lt;b&gt;State&lt;/b&gt;">
				<INPUT TYPE="hidden" NAME="response_7_question_id" VALUE="12902">
				<INPUT TYPE="hidden" NAME="question_type_7" value="StateSelect">
				<INPUT TYPE="hidden" NAME="label_7" value="State">

				
			</div> <!-- /inner -->

		</div> <!-- /layout_form_item -->

		
		<div id="form-item-12903" class="layout form item outer row-8 item-12903 row_num-80 row_pos-60 rowlength-3 type-Text" style=";position:relative;">

			<div class="inner">

				
							<b>Zip</b><span class="text-danger"> *</span>
					

							<input type="text"
								
									id="response_8"
									name="response_8"
								
								
								 style="width:80px;"
								
									
										value=""
									
								
								class="form-control type-Text row-8 item-12903"
							><!-- input -->

							
						<INPUT
							TYPE="hidden"
							NAME="response_8_required"
							VALUE="The field <b>Zip</b> is required. Please click your browser's back button and provide this value.">
					

				<input type="hidden" name="question_8" value="&lt;b&gt;Zip&lt;/b&gt; ">
				<INPUT TYPE="hidden" NAME="response_8_question_id" VALUE="12903">
				<INPUT TYPE="hidden" NAME="question_type_8" value="Text">
				<INPUT TYPE="hidden" NAME="label_8" value="Zip Code">

				
			</div> <!-- /inner -->

		</div> <!-- /layout_form_item -->

		
				</div> <!-- /The inner div, for the sake of IE -->
			
			<!-- The inner div, for the sake of IE -->
			<div id="layout_form_item" style="clear:both;border:0px solid orange;margin:0 0 0px 0;padding:0;min-height:0px;">
		

		<div id="form-item-12904" class="layout form item outer row-9 item-12904 row_num-100 row_pos-20 rowlength-2 type-Text" style="clear:both;;position:relative;">

			<div class="inner">

				
							<b>Phone</b><span class="text-danger"> *</span>
					

							<input type="text"
								
									id="response_9"
									name="response_9"
								
								
								 style="width:156px;"
								
									
										value=""
									
								
								class="form-control type-Text row-9 item-12904"
							><!-- input -->

							
						<INPUT
							TYPE="hidden"
							NAME="response_9_required"
							VALUE="The field <b>Phone</b> is required. Please click your browser's back button and provide this value.">
					

				<input type="hidden" name="question_9" value="&lt;b&gt;Phone&lt;/b&gt;">
				<INPUT TYPE="hidden" NAME="response_9_question_id" VALUE="12904">
				<INPUT TYPE="hidden" NAME="question_type_9" value="Text">
				<INPUT TYPE="hidden" NAME="label_9" value="Phone">

				
			</div> <!-- /inner -->

		</div> <!-- /layout_form_item -->

		
		<div id="form-item-12906" class="layout form item outer row-10 item-12906 row_num-100 row_pos-40 rowlength-2 type-Email" style=";position:relative;">

			<div class="inner">

				
							<b>Email</b><span class="text-danger"> *</span>
					

								<script type="text/javascript" src="/i4a/ams/include/checkemail.js"></script>
							

							<input type="text"
								
									id="response_10"
									name="response_10"
								
								
								 style="width:156px;"
								
									
										onchange="VerifyEmailAddress('iform', this.name,'<b>Email</b>')" value=""
									
								
								class="form-control type-Email row-10 item-12906"
							><!-- input -->

							
						<INPUT
							TYPE="hidden"
							NAME="response_10_required"
							VALUE="The field <b>Email</b> is required. Please click your browser's back button and provide this value.">
					

				<input type="hidden" name="question_10" value="&lt;b&gt;Email&lt;/b&gt;">
				<INPUT TYPE="hidden" NAME="response_10_question_id" VALUE="12906">
				<INPUT TYPE="hidden" NAME="question_type_10" value="Email">
				<INPUT TYPE="hidden" NAME="label_10" value="Email">

				
			</div> <!-- /inner -->

		</div> <!-- /layout_form_item -->

		
				</div> <!-- /The inner div, for the sake of IE -->
			
			<!-- The inner div, for the sake of IE -->
			<div id="layout_form_item" style="clear:both;border:0px solid orange;margin:0 0 0px 0;padding:0;min-height:0px;">
		

		<div id="form-item-12934" class="layout form item outer row-11 item-12934 row_num-120 row_pos-20 rowlength-2 type-Select" style="clear:both;max-width:50%;position:relative;">

			<div class="inner">

				
							How Did You Hear About This Meeting?
					

								<select
									id="response_11"
									name="response_11"
									
									
									class="form-control type-Select row-11 item-12934"
									>
									
										<option value=""></option>
									
									
										<option value="NYACP Website" >NYACP Website</option>
									
										<option value="NYACP Email" >NYACP Email</option>
									
										<option value="Friend/Colleague" >Friend/Colleague</option>
									
										<option value="Social Media" >Social Media</option>
									
										<option value="NYACP Mailing" >NYACP Mailing</option>
									
										<option value="Other" >Other</option>
									
								</select>
							
							
				<input type="hidden" name="question_11" value="How Did You Hear About This Meeting?">
				<INPUT TYPE="hidden" NAME="response_11_question_id" VALUE="12934">
				<INPUT TYPE="hidden" NAME="question_type_11" value="Select">
				<INPUT TYPE="hidden" NAME="label_11" value="Hear about meeeting">

				
			</div> <!-- /inner -->

		</div> <!-- /layout_form_item -->

		
		<div id="form-item-12935" class="layout form item outer row-12 item-12935 row_num-120 row_pos-40 rowlength-2 type-Select" style="max-width:50%;position:relative;">

			<div class="inner">

				
							Please note any dietary restrictions
					

								<select
									id="response_12"
									name="response_12"
									
									
									class="form-control type-Select row-12 item-12935"
									>
									
										<option value=""></option>
									
									
										<option value="a. Dairy" >a. Dairy</option>
									
										<option value="b. Peanuts" >b. Peanuts</option>
									
										<option value="c. Soy" >c. Soy</option>
									
										<option value="d. Vegetarian" >d. Vegetarian</option>
									
								</select>
							
							
				<input type="hidden" name="question_12" value="Please note any dietary restrictions ">
				<INPUT TYPE="hidden" NAME="response_12_question_id" VALUE="12935">
				<INPUT TYPE="hidden" NAME="question_type_12" value="Select">
				<INPUT TYPE="hidden" NAME="label_12" value="Dietary">

				
			</div> <!-- /inner -->

		</div> <!-- /layout_form_item -->

		
				</div> <!-- /The inner div, for the sake of IE -->
			
			<!-- The inner div, for the sake of IE -->
			<div id="layout_form_item" style="clear:both;border:0px solid orange;margin:0 0 0px 0;padding:0;min-height:0px;">
		

		<div id="form-item-12908" class="layout form item outer row-13 item-12908 row_num-140 row_pos-20 rowlength-1 type-Checkbox" style="clear:both;width:100%;position:relative;">

			<div class="inner">

				
							<label>
								<input
									type="checkbox"
									id="response_13"
									name="response_13"
									value="Yes"
									
									
									class="item type-Checkbox row-13 item-12908"
								><!-- input -->
					
					
							Check here if you are disabled and require assistance.  We encourage participation by all individuals. <br>
Advance notification is essential in order for us to serve you better. Please notify the NY Chapter in writing at least 30 days before the meeting. We’ll be glad to help!
					

							</label>
						
					
				<input type="hidden" name="question_13" value="Check here if you are disabled and require assistance.  We encourage participation by all individuals. &lt;br&gt;
Advance notification is essential in order for us to serve you better. Please notify the NY Chapter in writing at least 30 days before the meeting. We’ll be glad to help!">
				<INPUT TYPE="hidden" NAME="response_13_question_id" VALUE="12908">
				<INPUT TYPE="hidden" NAME="question_type_13" value="Checkbox">
				<INPUT TYPE="hidden" NAME="label_13" value="Disability">

				
			</div> <!-- /inner -->

		</div> <!-- /layout_form_item -->

		
				</div> <!-- /The inner div, for the sake of IE -->
			
			<!-- The inner div, for the sake of IE -->
			<div id="layout_form_item" style="clear:both;border:0px solid orange;margin:0 0 0px 0;padding:0;min-height:0px;">
		

		<div id="form-item-12923" class="layout form item outer row-14 item-12923 row_num-160 row_pos-20 rowlength-2 type-Select" style="clear:both;max-width:50%;position:relative;">

			<div class="inner">

				
							NYACP Member Rates
					

								<select
									id="response_14"
									name="response_14"
									
									
									class="form-control type-Select row-14 item-12923"
									>
									
										<option value=""></option>
									
									
										<option value="NYACP Master/Fellow/Member Registration Fee - $300" >NYACP Master/Fellow/Member Registration Fee - $300</option>
									
										<option value="NYACP Resident/Fellow Member Registration Fee - $100" >NYACP Resident/Fellow Member Registration Fee - $100</option>
									
										<option value="NYACP Medical Student Fee - $50" >NYACP Medical Student Fee - $50</option>
									
										<option value="NYACP Affiliate Member Registration Fee- $300" >NYACP Affiliate Member Registration Fee- $300</option>
									
										<option value="NYACP Member Guest Fee-$150" >NYACP Member Guest Fee-$150</option>
									
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