Thank you for your interest in attending the 2020 Tobacco-Free Workplace Summit. Please register for the event by completing the questions below. We look forward to seeing you there!

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* 1. Please share your contact information:

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* 2. Please select the workshop you would like to attend.

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* 3. Please list any question(s) or issue(s) related to tobacco prevention in the workplace that you would like to see addressed during the summit. (Optional)


I give permission to the Florida Department of Health (DOH) to record the appearance, physical likeness and/or voice on videotape, on film, or digital video disk, and/or take photographs of the appearance, and to release these images to the news media, use for posting on the DOH’s Intranet or Internet, use in internal or external publications, or use in any other manner deemed appropriate by DOH employees to publicize the DOH, its programs and activities, its employees, or to otherwise fulfill the mission of the DOH.

I acknowledge that the DOH is the sole owner of all rights in, and to, this visual and/or sound production and/or photograph(s) and the recordings, thereof, and that it has the right to use or reproduce the resulting images and/or sound as often as it finds necessary. The video and/or photographs may be used indefinitely by television, radio, newspapers, magazines, newsletters, brochures, Internet, intranet, or in other media once released.

The DOH has the right, among other things, to edit and/or otherwise alter the visual or sound recording, or photographs, as needed. I understand I will receive no compensation for the appearance of the above-named person or for participation in said productions. I agree to hold the DOH, its employees and other parties harmless against claim, liability, loss, or damage caused by, or arising from, my participation in this production.

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* 4. Date


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* 5. Do you agree to the above permission and release terms?