We #MakeHealth Fest 2015 - Registration
Join us at the 2nd annual We #MakeHealth Fest on Sunday, October 25, 2015 at 4th Floor, Palmer Commons, University of Michigan! This free and unique event will be a hands-on learning experience and a gathering for health innovators to #makehealth. Feel free to stop in anytime from 11 am - 6 pm!
Please complete this form to indicate the total number of people in your party/family, including children/minors. While registration is not required, we would like to plan accordingly for the complimentary lunch. If you do not pre-register, we cannot guarantee that lunch will be available to you. This also applies to our exhibitors, speakers, and volunteers! Registrations are due by Thursday, October 22nd.
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Are you an employee, faculty member, current student or affiliated with the University of Michigan?
How do you classify yourself?
Select all that apply
Public Health Professional
How many people are in your party?
Include children in the total count
Would you/your party like a complimentary light lunch?
Lunch will be provided by Pizza House. For those with special dietary requests, we will provide a personalized boxed lunch through a catering company. With this process, we hope to avoid any contamination issues or concerns.
Please identify any special dietary requests
For each individual in your party (e.g. Name #1, Name #2, Name #3), please indicate if vegetarian, vegan, gluten-free, specify food allergies, etc. If no special requests, leave blank.
Tell us if there is anything else we should know!
This year, we have streamlined the check-in process with pre-registration and electronic consent forms. If you would like to retain these for your records, paper copies of the blank forms will be available at the event. Note: You are indicating consent for all members of your party.
WE #MAKEHEALTH FEST Participation Form, Waiver and Release of Liability
I hereby acknowledge that I have been informed of the nature of the Activity and that I am aware of the hazards and risks which may be associated with participation in the Activity, including the risks of bodily injury, death or damage to property which may occur from known or unknown causes. I, on behalf of myself (if Participant is over 18) or the above-named Participant (if Participant is under 18), am exercising my own free choice to participate voluntarily in the above-named activities, and promise to take due care during such participation, including by complying with all applicable rules and instructions from the Activity Sponsor. While participating in the Activity, Participant is subject to the policies, rules and regulations of the Regents of the University of Michigan (“University”) and Activity Sponsor. Possession of fireworks, explosives, any weapon, illegal drugs or alcohol is prohibited and cause for immediate expulsion from the Activity. Further, any Participant repeatedly disobeying University or Activity Sponsor policies, rules or regulations may be expelled from the Activity. I hereby authorize Activity Sponsor, its employees, clinicians, trainers, nurses and agents the authority to seek, obtain, and approve any medical care and treatment including, but not limited to x-ray examination, anesthetic, medical, dental or surgical diagnosis, or treatment and medical care which may be recommended and provided under the general supervision of any physician or surgeon, for Participant which, in their judgment, is necessary for the health and well-being of Participant during his/her participation in the Activity. I further represent that I have health insurance covering myself (if over 18) or the Participant (if under 18) and agree and that I am solely responsible for any costs incurred and agree to hold the Activity Sponsor and University, their employees and agents harmless for any liability arising out of any good faith action taken in obtaining medical treatment for Participant. For Participants over 18 years old: I hereby release and discharge and hold harmless the Activity Sponsor and University, and its members, officers, agents, employees, and any other persons or entities acting on their behalf, against any and all damages, claims, demands, and causes of action whatsoever relating to injury, disability, death or other harm, to person or property arising from my participation in and/or presence at the above listed Activities, except for damages caused by the sole gross negligence or intentional misconduct of Activity Sponsor or University. I understand, accept, and assume all such hazards and risks, and waive all claims against the University, and other persons as set forth above. For Parent/Guardian if Participants are under 18 years old: In consideration for allowing Participant to participate in Activity, I, as parent and/or guardian of Participant, authorize Participant to participate in the Activity for the stated above and release and discharge and hold harmless the Activity Sponsor and University, and its members, officers, agents, employees, and any other persons or entities acting on their behalf, against any and all damages, claims, demands, and causes of action whatsoever relating to injury, disability, death or other harm, to person or property, except for damages caused by the sole gross negligence or intentional misconduct of Activity Sponsor or University, arising out of the participation of Participant in the Activity.
I HAVE HAD SUFFICIENT OPPORTUNITY TO READ THE ENTIRE DOCUMENT. I HAVE READ AND UNDERSTOOD IT, AND I AGREE TO BE BOUND BY ITS TERMS. The above agreements are binding upon us, our estates, heirs, representatives and assigns.
WE #MAKEHEALTH FEST Consent to Photograph or Record Electronically
I permit the University of Michigan to record a photographic image and or audio or video of me and my accompanying minor children at the Activity for educational, academic, or research purposes. If the faculty or staff of the University judges that education or research may benefit from the use of the photographs and/or recordings, the University may publish or sell them (not for profit) for academic purposes, or use them in any other professional manner that the University believes is proper, including, but not limited to: print publications, video streaming on University of Michigan websites, podcasting, and broadcast media. I understand that the pictures and recordings belong to the University, and I will not receive payment or any other compensation in connection with the pictures and recordings. I have had a chance to discuss this form with the University of Michigan staff and have received complete answers to all my questions. I release the University of Michigan from any and all liability that may or could arise from the taking or use of the pictures.
Yes, I acknowledge and consent to Photograph or Record at the We #MakeHealth Fest
Are you an exhibitor?
If yes, you will be sent to the Exhibitor Agreement Form
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