Ch21Con 2018: Registration Form

When filling in an electronic signature field, type "/s/" before your name in order for the signature to be legally binding. For example: /s/William Shakespeare

Saturday, August 4, 2018

Hilton Garden Inn - Chicago O'Hare

2930 S. River Road

Des Plaines, IL 60018

ADULT REGISTRATION FORM

Participant:

Name *

First Name Last Name

Nickname

Pronouns *

She/her, he/him, they/them, etc.

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Birth Date *

Month Day Year

E-mail Address *

Cell Phone *

- Area Code Phone Number

Home Phone

- Area Code Phone Number

Emergency Contact Information:

1. Name *

First Name Last Name

Cell Phone *

- Area Code Phone Number

Home Phone

- Area Code Phone Number

2. Name

First Name Last Name

Cell Phone

- Area Code Phone Number

Home Phone

- Area Code Phone Number

What would you like to eat for lunch? *

Cheese deep dish pizza Pepperoni deep dish pizza I have dietary restrictions and will need to order something different

Please note: Lunch will be provided at the conference. No outside food or beverages will be allowed at the conference. If you have dietary restrictions that mean you will not be able to eat deep dish pizza for lunch at the conference, we will be in contact with you about your alternate options.

- Recording, in any form, of any of the sessions or workshops is prohibited.

- Any applicable handouts will be available online after the conference.

- All participants retain the rights to any and all of their own writing shared at the event.

- Attendees are responsible for their own behavior throughout the conference. Chapter One Events has the right to request an attendee to leave with no refund, if that attendee is exhibiting inappropriate or harmful behavior, such as (but not limited to) being disrespectful to or harassing another person or using hate speech; being under the influence of drugs; damaging or otherwise not respecting the facility; exhibiting harmful behavior. No smoking or illegal drugs are allowed.

- Between sessions, time will be available to use the restrooms. Please make every effort to not leave during a session, as it is disruptive to the entire group.

- If you have any special needs, please email us at chapter21conference@gmail.com and we’ll accommodate you to the best of our abilities.

- This conference is for young adults, approximately 21-29 years of age. At various points of the conference, attendees will be in the same space as attendees of the Chapter One Young Writers Conference, some of whom will be minors. Please be aware of this and act appropriately.

- This permission form must be signed and received by Chapter One Events prior to the start of the conference. All information must be filled in on all pages of the form, including emergency contact information and all signatures and dates.

- Cancellation policy: Cancellations 30 days or greater prior to the start of the event will receive a full refund minus a $20 administrative fee. Cancellations fewer than 30 days before the start of the event will not be eligible for any refund.

- A lunch of deep dish, Chicago-style pizza will be provided at the conference venue and is included in conference tuition. No outside food or beverages is allowed on the premises. If you have dietary restrictions, alternate lunch options will be available at no extra charge.

PARTICIPANT CONSENT

I have read and agree to abide by the rules listed above and to conduct myself in a well-mannered and reasonable way throughout the conference.

Participant's Name *

First Name Last Name

Participant's Electronic Signature *

Date *

- Month - Day Year

at

: Hour Minutes

MEDIA RELEASE

I certify that photographs, digital images, and/or videography of myself participating in the Chapter One Events programs may be reproduced and used, without expectation of compensation of any kind, by Chapter One Events for its website, advertising or other promotional materials, or programs.

Participant's Electronic Signature *

Date *

- Month - Day Year

at

: Hour Minutes

LIABILITY RELEASE

I will participate in Chapter One Events’s Chapter Twenty-One Conference on Saturday, August 4, 2018.

I acknowledge that although all Chapter One Events events are well-supervised and Chapter One Events takes measures to minimize the risk of injury to participants in conference activities, Chapter One Events cannot guarantee that the participants will be free from hazards, accidents, and/or injuries during Chapter One Events sponsored events. I further recognize the importance of knowing and abiding by Chapter One Events rules to ensure safety. I agree that Chapter One Events, its agents, officers, employees, trustees, and volunteers will not be liable for any injury, death, damage, and/or loss to myself, and/or anyone claiming on my behalf, and I further agree to hold harmless, indemnify, and defend Chapter One Events, its agents, officers, employees, trustees, and volunteers for and from any and all damage during the time of my attendance and participation in Chapter One Events sponsored events.

Participant's Electronic Signature *

Date *

- Month - Day Year

at

: Hour Minutes

AUTHORIZATION FOR MEDICAL TREATMENT/ LIMITED POWER OF ATTORNEY

Allergies

Other Medical Conditions

Participant's Physician *

Physician's Phone *

- Area Code Phone Number

Medical Insurance Company *

Insurance Phone *

- Area Code Phone Number

Policy Holder *

First Name Last Name

Policy Number *

Group Number *

Participant's Name *

First Name Last Name

In the event of a medical emergency in which I become unable to participate in care and medical treatment decisions, I hereby appoint Chapter One Events leaders and volunteers to seek emergency treatment and delegate to each such person the power to consent on my behalf to all emergency treatment and/or medical care determined to be necessary or desirable by the attending physician, until such time that an emergency contact person, listed above, or their delegate is able to take over that role.

I agree to be responsible financially for any medical treatment and related expenses.

This Power of Attorney shall be in effect August 3 and 4, 2018.

Participant's Electronic Signature *

Date *

- Month - Day Year

at

: Hour Minutes

How did you hear about Ch21Con? *

If you heard about Ch21Con from a conference speaker, please specify which:

ORDER FORM

Ch21Con T-shirt & Sweatshirt - THE ORDER DEADLINE HAS PASSED

If you would like to purchase t-shirts or sweatshirts, you can select different styles and sizes at checkout. All t-shirts and sweatshirts are in adult sizes. If you order a t-shirt or sweatshirt, you will receive it upon arrival at the conference.

All t-shirts come with the Ch21Con logo, and the location and year of the conference. The two t-shirt styles are:

Unisex: traditional style
Bella: fitted style

The crew-neck sweatshirt comes with the Ch21Con logo and is in a "unisex," traditional style.

CHECK OUT *

Ch21Con 2018 Admission $ 99.99

Subtotal $ 0.00 Tax $ 0.00 Total $ 0.00

Be sure all electronic signature fields contain "/s/" before your name in order for the signature to be legally binding. For example: /s/William Shakespeare