PARTICIPANT REGISTRATION FORM
Section A - Participant Information If you experience any technical difficulties when using this form or if you have registration questions, please contact us at skrobem@mcmaster.ca
The asterisk (*) indicates a required field.
Section B – Delegate Registration
I am a:
General Pediatrician Pediatric Subspecialty – please specify: Family Physician Trainee – please specify: Select Trainee Type Fellow Resident Medical Student Allied Health – please specify:
Primary area of practice (please check all that apply):
Community Based Hospital Based University Affiliated Other – please specify:
How did you hear about this conference?
Brochure Email Workplace or Colleague Internet Search Attended Previous Conferences Other – please specify:
Registration fees include: admission to all sessions, program syllabus, letter of attendance, breakfast, lunch and nutrition break.
Section C – Payment Information Please verify all the information is correct. Your credit card statement will show this transaction as McMaster Pediatric Educational Conference.
Cancellation Policy All cancellations must be received in writing no later than March 29, 2019 for a full refund, less an administrative fee of $50.00. No refunds will be issued after this date.
I acknowledge that I have read and accept the above conditions.
Section D – Participant Consent & Release Agreement (Please scroll to the end and click on I AGREE after reading.)
CONSENT TO BE VIDEO RECORDED, AUDIO RECORDED, PHOTOGRAPHED, RECORDED AND/OR TO HAVE PUBLIC DISCLOSURE OF INFORMATION, AND WAIVER OF CONFIDENTIALITY FOR MEDIA PURPOSES.
I hereby give my permission and express written consent to Practical Pediatrics Conference (PPC) to digitally video record, videotape, digitally audio record and/or photograph me while I am attending and participating in the PPC. I further consent to PPC and its agents and assigns exhibiting, showing, re-producing, publishing, displaying, transmitting and other uses of all such video and audio recordings and photographic images in any media whatsoever in Canada or elsewhere, including presentations made for medical, scientific, educational and related marketing purposes.
I further acknowledge, confirm and agree that I shall have no right to inspect or approve any video and audio recordings and/or photograph(s) of me prior to it or their use by PPC or its agents and assigns in any manner and confirm and agree that I will receive no financial compensation arising from such use, including, without limitation, my providing services as a model.
I hereby fully and finally release PPC and its agents and assigns from any and all liability directly or indirectly arising out of the video and audio recordings and photographic images made and/or taken of me including, without limitation, how such recordings and images are used by PPC and its agents and assigns, the final form of such recordings and photographs and the timing, method and basis of it or their publication and distribution.
I acknowledge that PPC and its agents and assigns shall have the right to cancel any event offered or organized by PPC or its agents and assigns for which I may register to attend up to and including the day immediately prior to the scheduled commencement date of such event by email notification to me at the last email address I have electronically delivered to PPC. I hereby further release PPC and its agents and assigns from any and all claims relating directly or indirectly to such cancellation that I or my heirs, executors and administrators may have and hereby confirm and agree that PPC and its agents and assigns shall at no time be liable to me or my heirs, executors and administrators for any direct or consequential losses, damages, expenses or costs which I may suffer or incur as a result of a cancellation, including, without limitation, unnecessary travel expenses and loss of income.
WAIVER OF LIABILITY AND ASSUMPTION OF RISK ACKNOWLEDGEMENT.
In consideration of PPC permitting me to participate in any capacity whatsoever in the PPC (including but not limited to participation as an attendee or speaker), I hereby agree to the following terms:
I have read the foregoing Participant Consent & Release Agreement and confirm and agree that I fully understand its contents. I hereby warrant that I am of legal age and am competent to contract. I hereby provide and deliver both my express and informed consent as stated above and my agreement with the terms as outlined above by clicking on the I AGREE button as presented on this website and confirm that this Participant Consent & Release Agreement when given in this manner shall be forever binding upon me.
I agree to consent to have my name, address and email added to the mailing database for upcoming conferences: Yes No
Press Submit to complete your registration.
If you experience any technical difficulties when using this form or if you have registration questions, please contact us at skrobem@mcmaster.ca
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