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WI AHEC Interprofessional Healthcare Case Competition Intent to Participate, Release of Liability, Authorization for Photography, Recording or Interview and Competition Rules.
Please complete this form and pay the $35.00 competition registration fee no later than October 22nd, 2019, to be eligible to participate in the IPHcCC.

In consideration of my participation in the WI AHEC Healthcare Case Competition conducted by all of the regional and State offices of the Wisconsin Area Health Education Center, Inc. in the State of Wisconsin from Ocotber 8th, 2019 - January 10th, 2020 do voluntarily and without reservation, on behalf of myself, my heirs and my estate, release and discharge, indemnify, and hold harmless WI AHEC, regional and state AHEC centers and any other partnering organizations involved in this competition event.

Their officers, employees and agents from any liability for damage to or loss of property, injury, loss, delay, accident or sickness from what ever source, legal entanglements, imprisonment, death, loss of money or possessions, which might occur participating in this program. I attest and verify that I am aware of the dangers of travel within the State.

I understand that medical coverage is not provided for me by WI AHEC, regional AHEC centers, and any other partnering organizations. I verify that I have the appropriate medical coverage which will cover me during this camp. I understand that the cost of emergency medical evaluation and treatment, if needed, is my financial responsibility.

I acknowledge that I have been given ample opportunity to ask any questions concerning medical care prior to this event. I understand the conditions and activities of this competition. I understand that participation in this activity is strictly voluntary and I freely choose to participate.

I hereby expressly grant a representative of WI AHEC the right to photograph, video or audio record, and/or interview me.

In addition, I grant WI AHEC the right to use or publish my likeness and interview information for educational or communication purposes such as courses, pamphlets, video and audio programs, slide shows, websites or AHEC social media sites.

I understand that, once materials are released on the web, WI AHEC retains no further control over their use, and these items will no longer be protected.

This document is to confirm I that have received the WI AHEC Interprofessional Healthcare Case Competition Handbook from Jill Niemczyk, Program Director of the NEWAHEC, which includes information for the WI AHEC Interprofessional Healthcare Case Competition through October 8th - December 4th, 2019 and on the competition dates of January 9th & 10th, 2020.

By signing the information below, I agree to the rules of the competition as listed in the documents entitled “Interprofessional Healthcare Case Competition Rules”, provided in the WI AHEC Interprofessional Healthcare Case Competition Handbook. I am also accepting my position to participate in the entire Healthcare Case competition starting in October 2019 and concluding with the competition event date on January 9 & 10, 2020.
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PAYMENT: please click on link below to make an online payment. Each team member must pay the $35.00 registration fee.
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