1.Please provide your first and last name

2.Please indicate your province and institution

3.I am interest in attending the Roche Dinner on April 28th at 7:00pm

Yes

No

4.Please let us know if you have any allergies or dietary restricitions

5.Please share your email address so we may send you more information and details about the dinner

6.EXCLUSION OF LIABILITY

I acknowledge and confirm that in connection with my travelling to the event indicated in this form, which occurs on the date also indicated in this form, and for which event I have been invited by ROCHE DIAGNOSTICS, division of Hoffmann-La Roche Limited (“ROCHE”), I agree to not hold ROCHE responsible, to defend, to release and to hold harmless ROCHE, its related companies and/or affiliates, its directors, officers, employees, successors and assigns from any and all manners of action, claim, liabilities, damages, expenses and demands of any nature whatsoever, whether based on tort, contract or otherwise, directly or indirectly arising out of or in any way connected with my travelling to and my participation in the event. I am responsible to subscribe to and pay for any and all health, travel, life or other type of insurance I may deem prudent or necessary in the circumstances in relation to the event.

I accept