2023 IMC Speaker Registration

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2023 IMC Speaker Logistics and Travel

Travel Information

Name (as it appears on driver's license)(Required)
Address (as it appears on driver's license)(Required)
MM slash DD slash YYYY
Which night(s) will you plan to stay at the Embassy Suites by Hilton Downtown Denver? We invite you to participate in any or all days of the conference as your schedule permits.(Required)

Speaker Logistics

Please select from the following bio and headshot options(Required)
Max. file size: 50 MB.
Max. file size: 50 MB.
T-Shirt Size (Unisex Sizing)
I hereby grant MitoAction the irrevocable right and permission to use photographs and/or videos (including any presentation videos) of me on the MitoAction website, videos, publications, social media, promotional flyers or for any other similar purpose and agree that all such photographs and/or videos taken at the event shall remain the property of MitoAction.(Required)
While participating in events held or sponsored by MitoAction Inc., participants are encouraged to practice CDC guidelines to reduce the risk of exposure to COVID-19. MitoAction cannot guarantee that its participants, volunteers, partners, or others in attendance will not become infected with COVID-19. By attending a MitoAction event, you certify that you do not fall into any of the following categories: 1. Individuals who currently or within the past fourteen (14) days have experienced any symptoms associated with COVID-19, which include fever, cough, and shortness of breath among others; 2. Individuals who have traveled at any point in the past fourteen (14) days either internationally or to a community in the U.S. that has experienced or is experiencing sustained community spread of COVID-19; or 3. Individuals who believe that they may have been exposed to a confirmed or suspected case of COVID-19 or have been diagnosed with COVID-19 and are not yet cleared as non-contagious by state or local public health authorities or the health care team responsible for their treatment. DUTY TO SELF-MONITOR: Participants and volunteers agree to self-monitor for signs and symptoms of COVID-19 (symptoms typically include fever, cough, and shortness of breath) and, contact MitoAction at info@mitoaction.org if he/she experiences symptoms of COVID-19 within 14 days after participating or volunteering with MitoAction. LIABILITY WAIVER AND RELEASE OF CLAIMS: I acknowledge that I derive personal satisfaction and a benefit by virtue of my participation and/or voluntarism with MitoAction, and I willingly engage in MitoAction events and/or other fundraising activities (the “Activity”). RELEASE AND WAIVER. I HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE ANY AND ALL LIABILITY, CLAIMS, AND DEMANDS OF WHATEVER KIND OR NATURE AGAINST MITOACTION AND ITS AFFILIATED PARTNERS AND SPONSORS, INCLUDING IN EACH CASE, WITHOUT LIMITATION, THEIR DIRECTORS, OFFICERS, EMPLOYEES, VOLUNTEERS, AND AGENTS (THE “RELEASED PARTIES”), EITHER IN LAW OR IN EQUITY, TO THE FULLEST EXTENT PERMISSIBLE BY LAW, INCLUDING BUT NOT LIMITED TO DAMAGES OR LOSSES CAUSED BY THE NEGLIGENCE, FAULT OR CONDUCT OF ANY KIND ON THE PART OF THE RELEASED PARTIES, INCLUDING BUT NOT LIMITED TO DEATH, BODILY INJURY, ILLNESS, ECONOMIC LOSS OR OUT OF POCKET EXPENSES, OR LOSS OR DAMAGE TO PROPERTY, WHICH I, MY HEIRS, ASSIGNEES, NEXT OF KIN AND/OR LEGALLY APPOINTED OR DESIGNATED REPRESENTATIVES, MAY HAVE OR WHICH MAY HEREINAFTER ACCRUE ON MY BEHALF, WHICH ARISE OR MAY HEREAFTER ARISE FROM MY PARTICIPATION WITH THE ACTIVITY. ASSUMPTION OF THE RISK. I acknowledge and understand the following: 1. Participation includes possible exposure to and illness from infectious diseases including but not limited to COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; 2. I knowingly and freely assume all such risks related to illness and infectious diseases, such as COVID-19, even if arising from the negligence or fault of the Released Parties; and 3. I hereby knowingly assume the risk of injury, harm and loss associated with the Activity, including any injury, harm and loss caused by the negligence, fault or conduct of any kind on the part of the Released Parties.(Required)