Equity Matters in Healthcare Provider Healthcare Symposium Please use the form below to Register. Ignore this text box. It is used to detect automated systems. If you enter anything into this text box, then this form will not be processed. * First Name * Last Name * Address * City * State -- Please Select a State -- AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming * Zip * eMail Address * Phone Number * Age * Gender Profession Doctor Nurse Other * Required Event Liability Waiver In consideration of participating in Equity Matters in Healthcare (hereafter referred to as the Program), I understand that the Program may include physical activity, and that any physical activity may have injury and health risks associated with it. By signing below, I agree that the Program, Sponsors and Program Instructors do not assume any risk and responsibility for any and all accidents, injuries, illnesresponsibilityses and conditions of any kind that participants might sustain by reason of their participation in the Program. I fully accept and assume all such risks and all responsibility for losses, costs, and damages I incur as a result of my participation in the Activity. I hereby release, discharge, and covenant not to sue Gateway Medical Society, its Respective administrators, directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and if applicable, owners and lessors of premises on which the Activity takes place, (each considered one of the “RELEASES” herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence or the “releases” or otherwise, including negligent rescue operations; and I further agree that if, despite this release, waiver of liability, and assumption of risk I. or anyone on my behalf makes a claim against any of the Releases. I will indemnify, save, and hold harmless each of the releases from any loss, liability, damage, or cost which any may incur as the result of such claim. I have read this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK. AND INDEMNITY AGREEMENT, understand that I have given up substantial rights by signing it and have signed it freely and without any inducement and assurance of any nature and intend it be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid the balance. Not withstanding, shall continue in full force and effect. IMAGE USAGE This program will be videotaped and photographed and the use of the images is the sole discretion of Gateway Medical Society. If you wish not to have your images used, please inform us in writing. Liability Waiver By clicking this button I have read and agree with the Liability Waiver. Please check your email for your confirmation of registration.
