Presented by Montana Healthcare Foundation and Department of Health and Human Services

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* 1. Name (as you'd like it to appear on your name badge) 

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* 2. Email

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* 3. Organization 

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* 4. Title

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* 5. Registration Type  

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* 6. Days of Attendance 
*New grantees are required to attend both days

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* 7. Dietary restrictions

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* 8. Do you have any ADA disabilities that we need to be aware of? If yes, please list below: 

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* 9. The Montana Healthcare Foundation will be taking photos of this event for use on its website, social media pages, and for other materials consistent with its mission.

 

Please provide your consent by reading the image release below and clicking the ‘Approve’ button. If your image cannot appear in photos or recordings, please call our office at 406-451-7060 and we will discuss how to accommodate your needs.

 

For good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I hereby grant to Montana Healthcare Foundation (the “Foundation”) and its successors, assigns and licensees (collectively, the “Licensed Parties”) the right to photograph, audiotape and/or videotape me in connection with the activities and events I attend relating to the 2019 Montana Perinatal Behavioral Health Initiative Conference, and the right to use my name, voice, appearance, image, likeness, biographical information about me and statements that I have made during the event (collectively, the “Materials”) in any manner that supports the mission of the Foundation, in any form or media, now known or hereafter devised, in all languages in perpetuity.

 

I understand that I have no ownership rights in the Materials or in the work product that contains the Materials. I also understand that the Licensed Parties have no obligation to use the Materials or any of the rights set forth herein. 

 

I waive and release any claims that I may have against the Licensed Parties and their officers, directors, employees and agents based upon or arising from such uses as authorized herein, including without limitation, any moral rights of whatsoever description, any right to inspect or approve the references to me or the use of the Materials, any claims for invasion of privacy, violation of the right of publicity, defamation, and copyright infringement or for any fees for such use.

 

I represent and warrant that I have reached the age of majority in my jurisdiction, that I have read this Release prior to signing it and understand its contents, and that I am authorized to grant the permissions set forth herein.

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