Tech Conference Insurance Waiver Form

Tech Conference Insurance Waiver Form
Complete this form to request waiver coverage and acknowledge the terms for participating in the tech conference.
Participant Information
Participant Name
First NameMiddle NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Organization / Company Name
Role at the Conference
Emergency Contact Name
First NameMiddle NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Conference Coverage Details
Conference Name
Event Date or Date Range
MonthDayYear
Date
Venue / Location
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Coverage Request / Participation Area
I understand I am requesting insurance waiver coverage for participation in the tech conference
Waiver Acknowledgment and Signature
Participant Signature
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