Guest Registration - Celebration 2024

Please complete the following:

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* 1. Contact Information

Name:

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* 2. Course/Company Name

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* 3. Are you an AdventHealth employee?

Yes

No

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* 4. Title

Surgeon

Physician

Nurse

Resident/Fellow

Physician Assistant

Surgical Tech/ First Assist

Allied Health

Respiratory Therapist

Sales Representative

Other

Other (please specify)

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* 5. Photography in Labs

Attendee understands that absolutely no photos or video are permitted to be taken in the facility without prior written approval by Nicholson Center management.

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* 6. CADAVER BIOHAZARD STATEMENT AND ACKNOWLEDGEMENT

Advent Health Nicholson Center sponsors, in association with others, educational programs as means to further a better understanding of the diagnosis and treatment of individuals. You have applied to participate in the Workshop. In doing so, you have indicated that as a medical professional, you are familiar with the use of universal precautions and the handling of biohazardous waste. Human cadavers are utilized in the Workshop to further develop the surgical skills of the workshop participants. No currently available test method can offer complete assurance that infectious agents, including HIV and hepatitis viruses, are absent from the cadavers. Each cadaver should be considered as potentially infectious and handled with the same safety techniques utilized in normal surgery situations.
Throughout the Workshop, participants must wear protective apparel and use universal precautions in both the handling of specimens and in the use and disposal of sharp instruments. If you fail to adhere to these precautions, you may be asked to leave the Workshop.

ACKNOWLEDGEMENT
I have read the content of this form and agree to wear protective gear and adhere to universal precautions during my participation in the Workshop. In consideration of being permitted to participate in the Workshop, I hereby agree to release Advent Health and any other sponsor of the Workshop, their respective agents, officers, directors and employees of and from any and all liability, claims, demands or causes of action whatsoever (including any liability, claim, demand or cause of action that is attributable in whole or in part to the negligence of the hospital or that of its officers, directors, employees or agents) arising out of or related to any loss, damage or injury, including death, that may be sustained by me while
participating in the Workshop. I further agree to indemnify, hold harmless and defend Advent Health and any other sponsor of the Workshop, their respective agents, officers, directors and employees against all claims, suits, losses, damages and costs and reasonable attorney’s fees on account of any injury (including death) to me arising out of my participation in the Workshop.

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