Education Diversity Conference Form

EDUCATION DIVERSITY CONFERENCE FORM

Conference Details

Conference Name:    Date(s):

Location/Venue:

Participant Information

Date of Birth:    Student ID (if applicable):

Grade / Program:    Participant Type: Student Staff Chaperone Other

Emergency Contact & Medical Information

Relationship:    Phone:    Alternate Phone:

Health Insurance Provider:    Policy Number:

I authorize conference staff and designated medical personnel to administer or seek emergency medical treatment if necessary. I understand reasonable efforts will be made to contact emergency contacts prior to non-emergency treatment. By checking the box below I give medical authorization as described.

I authorize emergency medical treatment as needed.

Accessibility & Accommodations

Sessions & Program Participation

Please indicate intended participation (select all that apply):

Keynote Sessions Workshops Panel Discussions Networking Events

Travel & Chaperone Permission

Transportation provided by organizer: Yes    I permit participant to travel with group transportation: Yes

Media Release

Photographs, audio recordings, and video recordings may be taken during conference activities for program promotion, education and archival purposes. Please indicate your preference below.

I consent to the use of my image and likeness for publicity, educational, and archival purposes.
I do not consent to the use of my image and likeness.

Fees, Payment & Cancellation

Registration Fee: $    Payment Method:

Cancellation and refund requests must be submitted in writing no fewer than 14 days prior to conference start. A processing fee may apply. By signing this form the registrant or signer accepts financial responsibility for any unpaid fees unless otherwise agreed in writing by the organizer.

Code of Conduct & Liability Waiver

The Education Diversity Conference maintains expectations of respectful, inclusive, and harassment-free behavior. Participants must comply with all published policies and directions of conference staff. Disruptive or discriminatory conduct may result in removal from the event without refund.

By signing below, the signer affirms that all information provided is accurate to the best of their knowledge, agrees to comply with conference policies, and releases the conference organizers, venue, and agents from liability for injury or loss except as caused by gross negligence. The signer further agrees to indemnify and hold harmless organizers against third-party claims arising from the signer’s actions or omissions during the conference.

Parent/Guardian Information (If Participant is Under 18)

Participant is under 18 years of age: Yes

Acknowledgment & Signature

I certify that the information provided on this form is true and complete. I understand and accept the terms set forth above, including medical authorization, media release selection, code of conduct expectations, and financial responsibility. I hereby authorize the named participant to attend and participate in the Education Diversity Conference and related activities.

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