President:
Dr.Veena Chandrakar

Vice President:
Dr.Kulvinder Bajwa

Secretary:
Dr.Uttam Tripathy

Treasurer:
Dr.Raghu Athre

Immediate Past President:
Dr.Ashok Tripathy

Board of Directors:
Dr.Raghu Athre
Dr.Subodh Chauhan
Dr.Imran Mohiuddin
Dr.Manish Gandhi
Dr.Salil Deshpande
Dr.Lopa Mishra

IDC Charity Clinic Liaison:
Dr.Rakesh Mangal

HCMS Liaison:
Dr.Rakesh Mangal

MSRF Liaison:
Ankit Shah (BCM)
Khannan Athreya (UTH)

YPS Liaison:
TBA

IDA GALA 2012

Online Registration Form

Registration is not complete until the payment is made in the next screen

First Name * :

Last Name * :

Spouse / Guest :

Phone *:

- -

Address * :

City * :

State & Zip:

E-Mail *:

MEMBERS $115 / PERSON (# Of Persons):

AMOUNT:

MEMBERS $1200 / TABLE (# Of Tables):

AMOUNT:

MEMBERS-Children >10 (same fee as adults)(# Of Children) :

AMOUNT:

NON-MEMBERS $150 / PERSON (# Of Persons):

AMOUNT:

NON-MEMBERS $1400 / TABLE (# Of Tables):

AMOUNT:

NON-MEMBERS-Children >10 (same fee as adults)(# Of Children) :

AMOUNT:

MSRF $25 / PERSON (# Of Persons) :

AMOUNT:

Children 2 yrs - below 10 yrs (no fee) (# Of Children) :

AMOUNT:

TOTAL AMOUNT:

* Required information.

image gallery