Guest Speaker Event Waiver Form
Please complete this form to confirm your participation as a guest speaker and acknowledge the event waiver and media release terms.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Affiliation / Organization
*
Event Name
*
Event Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Talk / Session Title
*
Please confirm your agreement to the following: I acknowledge and agree to participate as a guest speaker at the above event. I grant permission for my session to be recorded, photographed, and used for event promotion, educational, and archival purposes by the event organizers. I release the organizers from any claims arising from the use of such materials and confirm my understanding of the event participation terms.
*
I agree to the terms and waiver above.
Signature
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Waiver
Submit Waiver
Should be Empty: