Virtual Roll Registration

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Cell Phone Number

Please enter a valid cell number.Format: (000) 000-0000.

Emergency Contact Name

First NameLast Name

Emergency Contact Phone

Please enter a valid phone/cell number.Format: (000) 000-0000.

Please provide your Chapter, Support Group or Organization Name:

Please select your Title(s)/Affiliation(s):

Do you have prior experience at Roll on Capitol Hill or Virtual Advocacy Day?

How many times have you attended Roll on Capitol Hill?

Photo Consent and Release Form

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to United Spinal Association, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to:

(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;
(b) Permission to use my name; and
(c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.

This consent is given in perpetuity and does not require prior approval by me

Virtual Roll on Capitol Hill Registration

Photo Consent and Release Form