Inspire:Diversity in Technology Conference

Inspire: Diversity in Technology Summit

Saturday, November 21, 2015

Thank you for your interest in attending the Inspire: Diversity In Technology Summit To reserve your seat, please fill out the information below.

First Name *

Last Name *

Sex: Male or Female *

Grade *

Age *

School *

Parent's Name *

Address *

City *

State *

Postal Code *

Phone *

Parent's Email Address *

Student's Email Address *

Will you be applying for the Scholarship?

Yes

Who invited you to the conference?

PHOTOGRAPH / VIDEO RELEASE FORM I hereby give permission for the Transcendence (Transcendence) to use, adapt, modify, reproduce and distribute any photograph(s)/video taken of me to promote, publicize and advertise our mission and its programs and services. I agree that Transcendence owns the copyright in these photographs, and I give my permission for these photographs to appear in newspapers and in Transcendence’s brochures, publications, presentations, website, press releases, and videos. I also understand that this is a public event and my picture may appear on the news or newspaper. I waive all rights including any right to inspect or to approve the photographs or finished versions of any materials incorporating the photographs, including written copy that may be created and appear in connection with the photographs, and I give the Transcendence the right to change, crop, or otherwise alter the photographs for these materials. On my behalf, I hereby release Transcendence, its agents, employees, licensees and assigns, from any claims and liabilities arising out of Transcendence’s use of these photographs and video, including claims for financial compensation now and in the future and for invasion of privacy, right of publicity, defamation, or libel. This waiver includes both known claims and those claims identified in California Civil Code Section 1542 which I may not yet know to exist. I understand that my name and picture may appear in future for Transcendence, newsletter, marketing materials and videos. *** This form grants permission for Transcendence to use your name and pictures/video without prior approval for the purposes of carrying out our mission. *

Yes, I grant permission.

No. I do not grant permission.

HEALTH INFORMATION If you answer YES to any of the questions, please explain using space provided below. ANY SPECIAL PROBLEMS OR PHYSICAL LIMITATIONS? ANY ALERGIES OR DIETARY RESTRICTIONS? TAKING ANY MEDICATIONS (prescribed or over the counter)? *

Meal Preference *

Special Requirements

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