RSV Coordinators Workshop
Friday, September 28, 2018

NO REGISTRATION FEES. There is no onsite registration, only those who have pre-registered will be admitted. Please register early since space is limited.

Section A - Participant Information
If you experience any technical difficulties when using this form or if you have registration questions, please contact us at louise@brunsconsulting.ca

The asterisk (*) indicates a required field.

Email Address*:
First Name*:
Last Name*:
Department*:
Institution/Hospital*:
Address Line 1*:
Address Line 2:
City/Town/Village*:
Province*:

Postal Code*:
Phone Number*: Ext:
Cell Number:
Fax Number:
   
Please indicate if you have any dietary restrictions, requirements or allergies:
If special meals are required at an extra cost, charges will be applicable.
   
Special Needs:
handicapped logo
   
Additional Comments:

 


Section B – Delegate Registration

I am a:

General Pediatrician
Pediatric Subspecialty – please specify:
Family Physician
Trainee – please specify:
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:

 

 


Section C
Please verify all the information is correct.

Cancellation Policy
All cancellations must be received in writing no later than September 22, 2017

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 RSV Coordinators Workshop (RSVCW) to digitally video record, videotape, digitally audio record and/or photograph me while I am attending and participating in the RSVCW. I further consent to RSVCW 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 RSVCW 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 RSVCW 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 RSVCW 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 RSVCW and its agents and assigns shall have the right to cancel any event offered or organized by RSVCW 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 RSVCW. I hereby further release RSVCW 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 RSVCW 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 RSVCW permitting me to participate in any capacity whatsoever in the RSVCW (including but not limited to participation as an attendee or speaker), I hereby agree to the following terms:

  1. I expressly warrant and represent that by attending the RSVCW I am knowingly, freely and irrevocably assuming all risk while participating in and or attending the RSVCW, in any manner whatsoever, regardless of how, where or when I may incur or sustain any injury, damage or loss, and whether or not resulting from the negligence of RSVCW or otherwise.
  2. None of RSVCW or its directors, officers, employees, agents or consultants (the “Releasees”) shall be liable nor held responsible in law by me, or my heirs, executors, assigns and any legal or personal representatives for any physical bodily injury (including loss of life or limb), damage or other loss (including but not limited to economic loss) incurred by me, however sustained or incurred at any time during my participation or attendance at the RSVCW, including my travel time to and from the RSVCW.
  3. I hereby irrevocably release and hold the Releasees harmless in respect of any and all liability for and in respect of my physical injuries and/or economic loss derived from my participation and involvement, in any manner, in the RSVCW.
  4. Once I have agreed to this Participant Consent and Release Agreement, it will constitute a full answer and defence in favour of the Releasees in relation to any claim that I may advance against same for any physical injury, damage or loss sustained by me while participating in or attending the RSVCW.
  5. I understand that it is a condition of my participation in the RSVCW that I must agree to the terms of this Participant Consent & Release Agreement and that I am under no requirement or compulsion to participate or attend the RSVCW and I am free to decline participation if these terms are not acceptable to me.
  6. While attending the RSVCW I agree to abide by all rules posted or otherwise provided to me, as well as all applicable federal, provincial and municipal laws and regulations.
I agree that regardless of actual causation, I am solely responsible for my safety while participating and attending the RSVCW.

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 louise@brunsconsulting.ca