Presenter Registration Form

Presenter Name

First Middle Last Suffix

Academic Degree Abbreviations

Name of Hospital/Company/Organization

Address

Street Address Address Line 2 City State ZIP Code

Presenter Email

Personal Cell Number

Brief Professional Biography (Max 300 Words)

I intend to participate in the conference dinner and lunches.

Yes
No

Please select which days:

Select All
Friday Lunch
Friday Evening Banquet
Saturday Lunch
Saturday Evening Event
Sunday Lunch

I would like to receive a conference t-shirt.

Yes
No

Please select which size:

I will be using my own computer for my lecture slide show presentation.

Yes
No

I would like to share an exhibitor table on:

Select All
Friday
Saturday
Sunday
I do not need an exhibitor table

I give the NODCC permission to audio-record or video-record my presentation to be aired on the NODCC’s website and/or YouTube Channel.

Yes
No

I give my permission for my presentation hand-outs to be published in the NODCC conference proceedings; posted on the NODCC website; and/or distributed in printed format.

Yes
No

A lectern and laptop computer with a LCD projector/screen will be provided for lectures, not moderated discussions or panels. The presentation computers are PCs. If your presentation has been developed in an Apple MAC, please bring your Apple computer to connect our projector. Please email your PowerPoint Presentation to conference@nodcc.org no later than June 10 so it can be loaded on a computer in advance. As back-up security, please bring your presentation to the conference saved to a flash drive.

Comments or Special Requests:

DCC Conference Participation Waiver of Liability and Hold Harmless Agreement
All attendees, presenters, exhibitors and volunteers are required to sign the following waivers.
Participation Waiver of Liability and Hold Harmless Agreement
All attendees are required to sign the following participation waiver of liability and photography & videotaping release. I/we the undersigned participant, have agreed to participate in the 2024 Disorders of the Corpus Callosum (DCC) Conference, including the IRC5 presentations, which begins on June 27, 2024 and ends on June 30, 2024. The National Organization for Disorders of the Corpus Callosum, (NODCC), a Minnesota non-profit organization headquartered in the State of California, United States of America, is dedicated to working with individuals diagnosed with a Disorder of the Corpus Callosum and their families. This document shall be interpreted under and pursuant to the laws of the State of California. Knowing, understanding, and fully appreciating all risks, I/we hereby expressly, voluntarily, and willingly assume all risks associated with my/our participation in the conference, including any and all losses, claims, or actions for any damages, theft, personal injury, sickness, disease, or death. The undersigned will pay any and all judgment decrees and costs, including attorney fees which may be rendered against or incurred by the 2024 DCC Conference, NODCC and IRC5 Boards of Directors, memberships, organizers, volunteers, agents, exhibitors, or vendors in all actions, or proceedings brought or caused by me/us. The undersigned hereby expressly and unconditionally waives and releases the NODCC and IRC5, all of its parents, subsidiaries, affiliates and partnerships, and their respective officers, directors, shareholders, partners, agents and employees, and their respective successors, heirs and assigns and each of them (individually and collectively, the “Released Parties”) from any and all rights and claims against the NODCC, the IRC5 and/or the Released Parties with respect to my/our participation and involvement in the 2024 DCC Conference, including but not limited to any alleged or actual negligence and intentional conduct or omissions to the maximum extent allowed under law. Any dispute or claim in law or equity arising out of this waiver and hold harmless agreement shall be decided by neutral, binding arbitration, except as provided by California law for judicial review of arbitration. The arbitration shall take place in the County of Orange, State of California in accordance with the rules of the American Arbitration Association.

Photography, Videotape, Audiotape Release Authorization
I/we, the undersigned participant , acknowledge my/our image may be photographed, videotaped and/or audio-taped during the course of the NODCC 2024 Disorders of the Corpus Callosum (DCC) Conference. I/we give permission for my/our photographed and videotaped image, audio recording, and printed survey comments during the 2024 DCC Conference to be printed, posted and/or published in official publications of the NODCC, including but not limited to directories, brochures, website, announcements, and conference materials. My/our signature(s) on this document is/are intended to bind not only myself/ourselves, but also my/our successors, heirs, representatives, administrators, and assigns.

Date:*

Please check boxes below:*

I/we give permission for my name, city, state, country, phone, and email address to be shared with members of the NODCC Community.
I/we give permission for my contact information (phone number and email address) to be shared with other conference attendees.

Signature*

Phone

This field is for validation purposes and should be left unchanged.

Title