ISSRT Northern CE Fall Event - REGISTRATION

Thank you for your interest in attending the Northern Region Continuing Education Event. Please complete the registration form below.

Question Title

1. First Name (Required.)

Question Title

2. Last Name (Required.)

Question Title

3. Email Address (Required.)

Question Title

4. Current Professional Status (Select one) (Required.)

Radiologic Technologist

Radiology College Program Director or Educator

Clinical Instructor/Preceptor

Imaging Student

Other

Question Title

5. ISSRT Membership Status (Select one) (Required.)

Active ISSRT Member (Free Event Registration)

Student ISSRT Member (Free Event Registration)

Non-Member ($20 Event Registration Fee)

PHOTO RELEASE AND CONSENT

Question Title

6. I hereby grant permission to ISSRT CE Event and its representatives to photograph, film, or digitally record me and to use my name, likeness, image, voice, and appearance in connection with the above-referenced event.

I understand and agree:

Usage Rights: These photos/videos may be used for promotional, educational, news, or commercial purposes in print, electronic, or digital media including but not limited to:

Websites and social media platforms

Brochures, flyers, and promotional materials

Press releases and news articles

Future event marketing

Release of Claims: I release the ISSRT its member, agents, and representatives from any and all claims, demands, or causes of action arising from the use of my likeness, image, or voice.

Yes

Northern Illinois Educator Huddle

Question Title

7. FOR EDUCTORS: Will you be attending the Northern Illinois Educator Huddle following the CE event (1:30PM)?

Yes, I plan to attend the Norther Illinois Educator Huddle

No, I will not attend the Educator Huddle