2022 ODER Auxiliary Faculty Form 2022 ODER Auxiliary Faculty Agreement Welcome Speaker! Thank you for sharing your time and expertise with Optometry Divas. Please submit the speaker agreement below 30 days before event date. Name(Required)Your typed name will count as your signature for the speaker agreement consent below. First Last Suffix/ Professional Credentials I will be presenting(Required) Alone With a Co-Presenter Co-Presenter Name(Required)Your typed name will count as your signature for the speaker agreement consent below. First Last Suffix Main Presenter Mobile Phone Number(Required)Main Presenter Email(Required) Main Presenter Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I will be providing the following presentation(s) at the 2022 Educational Retreat(Required)To add additional courses, click on the + sign on the right of the field. Presentation TitlePresentation DatePresentation Time Add RemoveHiddenIs the presentation approved for CE credit by the State Board of the area where your presentation is scheduled?(Required) Yes No HiddenDoes that state accept COPE credits from ARBO?(Required) Yes No HiddenPlease enter course # below from the state board.(Required)HiddenIs the presentation COPE approved by ARBO?(Required) Yes No If no, you will need to upload the lecture documents for us to submit for COPE approval. You will be redirected after you submit the form.HiddenPlease enter COPE# below from your state board.(Required)HiddenCE courses must be approved by either State Board or ARBO.Please enter the course information below so we can submit for approval with ARBO or state board. All state boards and ARBO require a minimum of 30 days to process CE approval requests. Your presentation may be rescheduled or cancelled if we don’t receive the course information on time. Please upload information in the field below. Uploads & ConsentSpeaker Headshot(Required)Please upload a headshot picture. File must be 64 MB or less. If the file is bigger, please email it to [email protected]Max. file size: 64 MB.Speaker Bio(Required)To help us introduce the speaker at the event, please upload the speaker bio belowMax. file size: 64 MB.Speaker CV Upload(Required)Please upload speaker CV below. Max. file size: 64 MB.Course Outline Upload(Required)Please enter course outline below. To qualify, the outline must be 2.5 pages long and must include – a course summary and learning objectives.Max. file size: 64 MB.Course Outline UploadPlease enter course outline below. To qualify, the outline must be 2.5 pages long and must include – a course summary and learning objectives.Max. file size: 64 MB.Course Outline UploadPlease enter course outline below. To qualify, the outline must be 2.5 pages long and must include – a course summary and learning objectives.Max. file size: 64 MB.Consent(Required) I agree to the terms of Optometry Divas Speaker AgreementIf the foregoing accurately sets forth your understanding of the terms of your engagement, please provide your consent. Your typed name above will count as your signature. As an auxiliary faculty member for the 2022 Optometry Divas Education Retreat, we are pleased to provide you with the following: FREE registration to the entire event, a value of $449. Once you submit your agreement you will be automatically registered for the event. Remuneration for services in the amount of $100 per hour. In addition, you will be reimbursed for the following: o Up to $50 total for meals and incidentals o 0.56 cents per Mileage and Tolls reimbursed if you’re driving to event Faculties will make their own travel arrangements, but Optometry Divas will reimburse hotel reservations for up to 1 night. Any additional stay will be at faculty’s expense. Hotel Guest Room Group Discounted Rates – $185 per night + fees and taxes. For the purpose of this Agreement, you agree to the following: A/V Provision Audio-Visual: The following audio-visual equipment will be available for your use: Computer/LCD projector, Projection Screen, Laser Pointer Photography and Videotaping Photographing, videotaping and/or audiotaping of any kind is prohibited during the conference without the permission of Optometry Divas. Optometry Divas may engage in photographing, videotaping and/or audiotaping the meeting for post meeting promotion and/ or educational purposes. However, the content of your presentation will not be recorded. Conduct 1. You will not promote any books, products, consulting services, or any other products or services, during this program without prior written approval from Optometry Divas. 2. There will be no changes in the date or time of this presentation without approval of Optometry Divas. 3. You understand that 50 minutes constitute one hour of continuing education. You agree to present all information contained in the detailed outline within the allotted time. 4. You will receive your honorarium within 30 days of your presentation . 5. Liability & Insurance a. Speaker agrees to fully defend, indemnify, and hold harmless Optometry Divas from any and all claims, lawsuits, demands, causes of action, liability, loss, damage and/or injury, of any kind whatsoever (including without limitation all claims for monetary loss, property damage, equitable relief, personal injury and/or wrongful death), whether brought by an individual or other entity, or imposed by a court of law or by administrative action of any federal, state, or local governmental body or agency, arising out of, in any way whatsoever, any acts, omissions, negligence, or willful misconduct on the part of speaker while a participant of the Optometry Divas event, its officers, owners, personnel, employees, agents, contractors, invitees, or volunteers. This indemnification applies to and includes, without limitation, the payment of all penalties, fines, judgments, awards, decrees, attorneys’ fees, and related costs or expenses, and any reimbursements to Optometry Divas for all legal fees, expenses, and costs incurred by it. 6. Meeting Cancellation Policy a. If the local event is abbreviated or cancelled due to circumstances beyond its control, including but not limited to, civil disturbance, earthquake, electrical outage, explosion, fire, strike or labor unrest, flood, hurricane, tornado or other acts of God, an act of war, or the act of any government, then this agreement shall be suspended without penalty and rescheduled within twelve (12) months. If, in the sole discretion of Optometry Divas it cannot be rescheduled, both parties shall be excused from this agreement without penalty or liability of any kind to the other and all remunerations and reimbursements will be forfeited.