Florida School Nutrition Association s1

Florida School Nutrition Association Region VII Seminar Registration Form

Date: 10/22/2016 Time of Registration: 7:30-8:00 am Location: Ronald Regan Senior High Hotel Suggestion: Court yard Miami West School about 2 miles from 11580 NW 105th Street 8600 NW 107th Ave. school( DID NOT RESERVE Miami, FL 33178 Doral, FL 33178 ANY ROOMS) n Registration Fee: Pre Conference: $15.00 Pre-Registration Due: Date:10/07/2016 On Site: $20.00 Chapter Tables: No Charge Theme: Harvest Theme

Local Associations are asked to register as a group. Please submit individual registration forms and checks made payable to your local association. Your local association in turn will submit all registration forms and one check payable to BSNA to cover all registration fees to: Anita Carnahan, Chapel Trail Elementary, 19595 Taft Street, Pembroke Pines, FL 33029. Continental Breakfast Great Educational Sessions BBQ Lunch Door prizes Drawing for either a Limited Annual Conference Registration or Legislative Action Caucus Registration

Name: ______County: ______Address: ______City, State, Zip: ______Phone number ______Is this your first Region Seminar? Yes ___ No ____ Are you a member of FSNA? Yes___ No_____ Would you like to reserve a Sales Table for your Chapter? Yes ___ No ___ FSNA is committed to ensuring all meeting activities are accessible. To discuss specific needs, including dietary, contact your Region Director, Anita Carnahan, on or before Date. 10/12/2016 Daytime Telephone: 754-323-5010; Email: [email protected]

LIABILITY AND INDEMNIFICATION AGREEMENT I request that you accept me as a participant at the Florida School Nutrition Association (FSNA) Region Seminar. I understand there is some risk inherent in traveling to and from, and as a result of, attending the Seminar. The undersigned hereby releases the FSNA and the committees, members, officers, employees, as well as other participants and other persons who may take part in said seminar from all liability for injury, death and property damage that may be suffered in connection with such activities, where due to negligence or otherwise, accepting such risks involved and waiving all rights of any kind that might otherwise arise. The undersigned agrees to indemnify FSNA, its committees, members, officers, employees, and director against all judgments obtained and against the cost of defense of such claims including reasonable attorney’s fees.

Signature Required for Registration: ______

(If sending in the group registration form below, have each registrant sign below his or her name on the registrant list as indicated. Each registrant must sign below their name if you are using the group registration form. If using the group registration form, you do not have to send in this separate form for each registrant.) Florida School Nutrition Association Region VII Seminar CHAPTER GROUP Registration Form

Local Associations are asked to register as a group. In lieu of submitting individual registration forms please list all attendees from your district and submit with one check payable to BSNA to cover all registration fees to: Anita Carnahan, Chapel Trail Elementary, 19595 Taft Street, Pembroke Pines, FL 33029

Chapter: ______

Contact Person for this Registration List______

Phone Number: ______

Email Address: ______

Chapter Sales Table Requested? ______

LIABILITY AND INDEMNIFICATION AGREEMENT I request that you accept me as a participant at the Florida School Nutrition Association (FSNA) Region Seminar. I understand there is some risk inherent in traveling to and from, and as a result of, attending the Seminar. The undersigned hereby releases the FSNA and the committees, members, officers, employees, as well as other participants and other persons who may take part in said seminar from all liability for injury, death and property damage that may be suffered in connection with such activities, where due to negligence or otherwise, accepting such risks involved and waiving all rights of any kind that might otherwise arise. The undersigned agrees to indemnify FSNA, its committees, members, officers, employees, and director against all judgments obtained and against the cost of defense of such claims including reasonable attorney’s fees.

By registering and signing below your name you are agreeing to the above Liability and Indemnification Agreement above. Your signature below your name is REQUIRED for Registration.

1st Region FSNA Name-Please Print and then Address, City, State, Zip Phone # Seminar? Member? sign below name

1. Yes or No Yes or No

5. Yes or No Yes or No LIABILITY AND INDEMNIFICATION AGREEMENT I request that you accept me as a participant at the Florida School Nutrition Association (FSNA) Region Seminar. I understand there is some risk inherent in traveling to and from, and as a result of, attending the Seminar. The undersigned hereby releases the FSNA and the committees, members, officers, employees, as well as other participants and other persons who may take part in said seminar from all liability for injury, death and property damage that may be suffered in connection with such activities, where due to negligence or otherwise, accepting such risks involved and waiving all rights of any kind that might otherwise arise. The undersigned agrees to indemnify FSNA, its committees, members, officers, employees, and director against all judgments obtained and against the cost of defense of such claims including reasonable attorney’s fees.

13. Yes or No Yes or No LIABILITY AND INDEMNIFICATION AGREEMENT I request that you accept me as a participant at the Florida School Nutrition Association (FSNA) Region Seminar. I understand there is some risk inherent in traveling to and from, and as a result of, attending the Seminar. The undersigned hereby releases the FSNA and the committees, members, officers, employees, as well as other participants and other persons who may take part in said seminar from all liability for injury, death and property damage that may be suffered in connection with such activities, where due to negligence or otherwise, accepting such risks involved and waiving all rights of any kind that might otherwise arise. The undersigned agrees to indemnify FSNA, its committees, members, officers, employees, and director against all judgments obtained and against the cost of defense of such claims including reasonable attorney’s fees.