Name *

First Name

Last Name

Phone *

(###)

###

####

I agree that my name, title, organization and email as entered in this registration form can be shared with other participants. *

Yes

I want to limit what is shared.

Hotel Stay

Do you plan on staying in the hotel block? The cost is $279/night plus taxes and fees. If yes, please indicate which night(s) you would like to stay in the hotel block.

Thursday, September 26

Friday, September 27

Photo Release *

I hereby grant the Foundation to Advance Vascular Cures permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of the Foundation to Advance Vascular Cures and will not be returned. I hereby irrevocably authorize the Foundation to Advance Vascular Cures to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. I hereby hold harmless, release, and forever discharge the Foundation to Advance Vascular Cures from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE.