2023 Child Health Equity Summit Registration Form

Full Name*

First NameLast Name

Phonetic Pronunciation of Your Full Name*

First NameLast Name

Degrees (e.g., MPH, PhD)*

Salutation (e.g., Ms., Dr.)*

Pronouns (e.g., They/Them)*

Organization Name*

Title (e.g., Director)*

Field / Industry (e.g., Healthcare)*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

example@example.com

Phone Number*

I will attend:

Day 1 - May 18th, 2023Day 2 - May 19th, 2023

Accommodations*

Dietary Restrictions

Allergies*

Anything Else You'd Like to Share*

COVID-19 WAIVER RELEASE - I understand that hosts of the Child Health Equity Summit are dedicated to protecting the health and safety of attendees. I attest that I will not attend the event if I am experiencing any symptoms of illness such as a fever, cough, or shortness of breath. If I develop these symptoms, I agree that I will leave the event premises immediately. I am aware that I must follow the safety and hygiene protocols of the event organizer. Additionally, I will not attend the event if I have:· Traveled internationally within two weeks of the event;· Traveled to a highly impacted area within the United States within two weeks of the event;· Knowingly been exposed to a person with a confirmed or suspected case of COVID-19 within two weeks of the event; and/or· Been diagnosed with COVID-19 within two weeks of the event. I will following recommended guidelines as much as possible with practicing social distancing, trying to maintain separation of six feet from others, and otherwise limiting my exposure to the coronavirus. I understand, acknowledge, and assume the risks and dangers associated with participation in attending the event, including without limitation, the potential for serious bodily injury, sickness, and disease (including COVID-19); situations unknown to or beyond the immediate control of the event organizers; and other undefined, not readily foreseeable, and presently unknown risks and dangers ("risks"). I understand that these risks may be caused in whole or in part by my own actions or inactions, the actions or inactions of others participating in the event, or the negligent acts or omissions of the event organizers, and I hereby expressly assume all such risks and responsibility for any damages, liabilities, losses, or expenses which I incur because of my participation in the event.*

I agree

CONSENT FOR PARTICIPATION AND USE OF PHOTOGRAPH AND/OR INTERVIEW FOR PUBLICATION - I authorize, in a manner consistent with M.G.L. c. 214, § 3A, UMass Memorial Health Care and its entities (“UMass Memorial”) to take, edit, exhibit, publish or make use of my name, photos, videos, audio-recordings, or content from interviews, of me during the course of my (or my child’s) care/treatment as a patient, work, volunteering, or related activity. Images and interview information become the property of UMass Memorial and, in some cases, a specified media outlet. I understand that I will not receive payment or other consideration in relation to this consent. I release UMass Memorial and its member entities from any legal liability. I also understand that I may revoke this consent at any time by contacting UMass Memorial Medical Center’s Marketing and Communications Office at 281 Lincoln Street, Worcester, MA 01605 or by calling 508-334-8523. Revocation will not apply to information that has already been released based on this consent. For patients: I understand that my decision to sign, or not to sign, this Consent will not affect my ability to receive health care at UMass Memorial. Media, marketing, or educational interviews, photographs, videos, or other electronic images are not made part of my medical record For non-patients: I understand that my decision to sign or not to sign this Consent will not affect my employment or relationship with UMass Memorial. Media, marketing, or educational interviews, photographs, videos, or other electronic images are not made part of any employment record. I have read and understand the statements above and, without coercion, I willingly consent to participation and the use and disclosure as specified above.*

I agree

Signature*

Powered by Jotform Sign Clear