Location: Emory Conference Center Hotel, Atlanta, Georgia

September 18th - September 19th, 2026.

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* 1. The REPRESENT! NCCPA Summit starts at 7 a.m. on Friday, Sept. 18th, with breakfast, followed immediately by sessions. Please acknowledge by completing this registration that you plan on attending.

There will be a waiting list so please let us know if your plans change and we can open a space for another person. Deadline for registration is July 15, 2026. Please notify us by email pr@nccpa.net with any questions or cancellation.

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* 2. Are you a PA student? If so, you will be sent another application to submit.

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* 3. First Name and last name with your credentials (for nametag):

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* 4. Address

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* 5. Employer:

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* 6. Job Title:

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* 7. Do you have any dietary restrictions? (Select all that apply.)

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* 8. Any special needs that may require accommodations to fully participate?

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* 9. I would like to receive a complimentary ticket to The National Center for Civil and Human Rights for a group event (self-guided tour) on Saturday Sept. 19th, starting at 2 pm

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* 10. I will attend the reception event on Saturday, 4-6 pm, September 19th at National Center of Civil Rights.

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* 11. Are you interested in submitting an abstract for the poster session?

Poster application deadline is July 1, 2026. Notification to applicants is July 30, 2026 (see https://www.nccpa.net/represent-summit/)

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* 12. Please sign below with your full name below the Authorization and Release Agreement for Photography, Recording, and Written Content:

1. I hereby irrevocably grant to NCCPA, including its legal representatives, assigns, affiliates and those acting under its permission and upon its authority (collectively, “NCCPA”), the absolute right and unrestricted permission to:
a. Photograph, video record, and sound record, and publish or otherwise use my photograph, video recording, sound recording, likeness, as provided by me to NCCPA or taken or recorded by NCCPA in connection with [REPRESENT! NCCPA Summit, NCCPA website, PAsDoThat website, PA Insights with NCCPA podcast and all NCCPA social media channels], and/or name in whole or in part, for any purposes whatsoever, and to
b. Copy, edit, alter, retouch, revise and otherwise change my photograph, video recording and/or sound recording, and to
c. Use, re-use, publish, and republish, and license the right to use, re-use, publish and republish my photograph, video recording, sound recording, likeness and/or name in its sole discretion, in any medium or form of distribution now or hereafter known including, without limitation, print, illustrations, electronic media, and the Internet, brochures, letters, art, promotion, advertising or trade, and to
d. Copy, edit, alter, revise and otherwise change any written content (including, but not limited to, quotes and articles) written by me for NCCPA’s use.
2. I understand that I will receive no compensation for the use of my photograph, likeness, video recording, sound recording, name, and/or written content.
3. I understand and agree that NCCPA shall have, and do hereby grant and assign to NCCPA, all rights, title, and interest in and to the photograph, video recording, sound recording, likeness, and/or written content, which shall include all rights of ownership and to register such ownership in trademark, copyright, or otherwise.
4. I hereby waive any right that I may have to inspect and/or approve the finished product or the advertising copy or printed matter that may be used in connection with my photograph, video recording, sound recording, likeness, written content, and/or name or the use to which it may be applied. I understand that my photograph, video recording, sound recording, likeness, written content, and/or name may be used in various multi-media platforms, including but not limited to, social media, newsletters, podcasts, videos, website content, and publications.
5. I hereby release, discharge and agree to save harmless NCCPA and its officers, directors, employees, agents, legal representatives, assigns, affiliates and those acting under its permission and upon its authority, from any liability by virtue of any use or publication of my photograph, video recording, sound recording, written content, likeness and/or name, including, without limitation, claims for copyright infringement, claims for libel or invasion of privacy, and any liability arising by virtue of any blurring, distortion, or alteration that may occur in the finished product.
6. I understand this agreement does not have an expiration date and hereby release NCCPA to use my photograph, video recording, sound recording, written content, likeness and/or name indefinitely.
7. I hereby warrant that I am at least 18 years of age, that I have the right to contract in my own name with regard to the above terms, and that this release is signed voluntarily and under no duress, disability, or undue influence.

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