General Registration Page 2021 Retreat General Registration Form Doctor's Name - #1* First Last Phone*Email* Attending Banquet (Yes/No)*YesNoAre you bringing or registering for other doctors?*YesNoAdditional DoctorsPlease enter the information for the additional doctor registrations. Click on the + button to the right of the fields to add more names.Doctor's First NameDoctor's Last NameDoctor's Phone NumberDoctor's EmailAttending Banquet (Yes/No) CE InformationIf you need CE credits, please provide the requested information below for each doctor attending the event. Click on the + button to the right of the fields to add more names.Doctor's First and Last NameLicense NumberOE Tracker NumberState(s) Licensed Practice NameAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about this meeting*EmailSocial MediaColleague/Ambassador/MemberPlease enter the name of the colleague, member or ambassador who referred you below.Help your colleague increase their chance of winning the FREE Hawaii Vacation when you add their name below. Please select all that apply below.* Bringing Staff Members Attending VIP Event N/A Staff MembersPlease enter the information for each staff member you are bringing to the event. Click on the + button to the right of the fields to add more names.Staff First and Last NamePositionPhone NumberEmailAttending Banquet (Yes/No) VIP Experience EventPlease enter the information for each person attending the VIP Experience event. Click on the + button to the right of the fields to add more names.First and Last NamePositionPhone NumberEmail Consent* I agree to the terms belowLIABILITY & INSURANCE Attendee agrees to fully defend, indemnify, and hold harmless Optometry Divas Educational Retreat (ODER), 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 Exhibitor while a participant of the ODER, 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 the ODER, OPTOMETRY DIVAS, for all legal fees, expenses, and costs incurred by it. Exhibitors wishing to insure their exhibit materials, goods, or wares against theft, damage by fire, accident, or loss of any kind must do so at their own expense. MEETING CANCELLATION POLICY If the ODER is abbreviated or canceled 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 both parties shall be excused from this agreement without penalty or liability of any kind to the other and 70% of funds collected shall be refunded. EVENT REGISTRATION REFUND POLICY Registration can be transferred to another person if requested in writing by e-mail to [email protected]OptometryDivas.com by the original registrant at least two weeks before the event. No substitution is allowed within the last two weeks before the event. All refunds are subject to a $50.00USD administrative fee. If canceled up to four weeks before the event, 100% of the registration fee (less the administrative fee) will be refunded. If canceled between four and two weeks before the event, 50% of the registration fee (less the administrative fee) will be refunded. No refund is given if canceled within two weeks of the event. PHOTOGRAPHY AND VIDEOTAPING Photographing, videotaping, and/or audiotaping of CE lectures is prohibited during the conference without the permission of ODER. ODER may engage in photographing, videotaping, and/or audiotaping the meeting for post-meeting promotion and/ or educational purposes.