Presenter Registration Form

Presenter Name

First Middle Last Suffix

Title

Name of Hospital/Company/Organization

Address

Street Address Address Line 2 City State ZIP Code

Presenter Email

Personal Cell Number

Brief Summary of your Career (150 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 require an Internet connection to show embedded video content in my slide 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-out to be released to the NODCC and to be published in the 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 Release Authorization
I, the undersigned participant, have agreed to participate in the Disorders of the Corpus Callosum (“DCC”) Conference 2020 that begins on June 26, 2020 and ends on June 28, 2020. 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 hereby expressly, voluntarily, and willingly assume all risks associated with my 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 DCC Conference 2020 organizers, volunteers, agents, exhibitors, vendors in all actions or proceedings brought or caused by me.
The undersigned hereby expressly and unconditionally waives and releases the NODCC and 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 and/or the Released Parties with respect to my participation and involvement in the DCC Conference 2020, 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 Los Angeles, State of California, in accordance with the rules of the American Arbitration Association.
Photography, Videotape, Audiotape Release Authorization
I, the undersigned participant, acknowledge that my image may be photographed, videotaped and/or audio-taped during the course of the Disorders of the Corpus Callosum Conference 2020 I give permission for my photographed and videotaped image, audio recorded and printed survey comments during the 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.

By signing below on this document, I intend to bind not only myself, but also my / our successors, heirs, representatives, administrators, and assigns.

Date:

Signature:

Name

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