<p> Florida School Nutrition Association Region 5 Seminar Registration Form </p><p>Date: September 28th, 2013 Time of Registration: 7:30-8:00 am Location: Safety Harbor Resort & Spa Hotel Suggestion: Safety Harbor Resort & Spa 105 N Bayshore Dr rooms have been 105 N Bayshore Dr Safety Harbor, Fl 34695 blocked for Fri-Sun at Safety Harbor, Fl 34695 a $109/night rate. 727.726.1161 Registration Fee: Pre Conference: $25 Pre-Registration Due: September 13th, 2013 On Site: $30 Chapter Tables: $10 Theme: Bridging the Gap!</p><p>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 Region 5 Florida School Nutrition Association to cover all registration fees to Heather Wellings, 2920 N 40th St, Tampa Fl 33605. Continental Breakfast Great Educational Sessions Lunch & Wellness Fair School Lunch Battle Door prizes Drawing for either a Limited Annual Conference Registration or Legislative Action Caucus Registration</p><p>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, Heather Wellings (813.840.7104 or [email protected])</p><p>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.</p><p>Signature Required for Registration: ______Florida School Nutrition Association Region 5 Seminar CHAPTER GROUP Registration Form </p><p>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 Region 5 Florida School Nutrition Association to cover all registration fees to: Heather Wellings, 2920 N 40th St, Tampa Fl 33605.</p><p>Chapter: ______</p><p>Contact Person for this Registration List______</p><p>Phone Number: ______</p><p>Email Address: ______</p><p>Chapter Sales Table Requested? ______</p><p>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.</p><p>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.</p><p>1st Region FSNA Name-Please Print and then Address, City, State, Zip Phone # Seminar? Member? sign below name</p><p>1. Yes or No Yes or No</p><p>2. Yes or No Yes or No</p><p>3. Yes or No Yes or No</p><p>4. Yes or No Yes or No</p><p>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.</p><p>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.</p><p>1st Region FCNA Name-Please Print and then Address, City, State, Zip Phone # Seminar? Member? sign below name</p><p>6. Yes or No Yes or No</p><p>7. Yes or No Yes or No</p><p>8. Yes or No Yes or No</p><p>9. Yes or No Yes or No</p><p>10. Yes or No Yes or No</p><p>11. Yes or No Yes or No</p><p>12. Yes or No Yes or No</p><p>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.</p><p>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.</p><p>1st Region FCNA Name-Please Print and then Address, City, State, Zip Phone # Seminar? Member? sign below name</p><p>14. Yes or No Yes or No</p><p>15. Yes or No Yes or No</p><p>16. Yes or No Yes or No</p><p>17. Yes or No Yes or No</p><p>18. Yes or No Yes or No</p><p>19. Yes or No Yes or No</p><p>20. Yes or No Yes or No</p><p>21. Yes or No Yes or No</p>