Sponsorship Registration

Local Event Exhibitor Registration Form

Please complete this form to register as an exhibitor at our local events. The information collected on this form will be used for internal administrative purposes only.

Today's Date(Required)

Name of Company Representative(Required)

Please enter the name of the representative scheduled to attend the event.

First Last

Company Name(Required)

Company Address(Required)

Street Address Address Line 2 City State ZIP Code

Best Phone Number to Reach The Representative(Required)

Representative Email(Required)

What are your primary reason for sponsoring our events?(Required)

Your answers to this question will help us create a world-class experience for you as well.

How can we best help you get a successful outcome?

We are excited to partner with you at our upcoming event. To help us better serve you, can you tell us 1-3 things we can do to help you reach your goal?

Which category of ODs is your ideal prospects?(Required)

Private Practice Owners

Private Practice Associates

Corporate Lease Owners

Corporate Lease Associates

Independent Contractors

Ophthalmology Group Associates

Any Practicing Optometrist

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Do you want to sign up for the multiple event bundle option?(Required)

Yes

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Please list the events you want to exhibit in below:(Required)

Please click on the + sign to the right of the field to add more rows. For virtual events, type virtual in the city box.

City

Ambassador Name

Event Theme

Event Date

In what city and state is event for your exhibit?(Required)

For virtual events, please type virtual as the city and chose FL as the state.

City State

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In what city and state is event that you are sponsoring?(Required)

Please click on the (+) icon on the right of the “state” field to add additional cities and states.

City

State

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Which event(s) are you sponsoring?(Required)

Please select event below. If the event you’re sponsoring is not listed, please identify the event in the “other” field below. For event bundling options, please email [email protected] for more details.

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Other(Required)

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I am completing this form for events scheduled for the following year.(Required)

2023

2024

Choose your 2023 Sponsorship package below.(Required)

Elite Exhibit Level – $3500

Certified Exhibit Level – $2500

Associate Exhibit Level – $1500

Other

Choose your sponsorship package below.(Required)

Elite Exhibit level – $3500

Certified Exhibit Level – $2900

Associate Exhibit Level – $1500

Other

How will you be processing payment?(Required)

I will pay by credit card in the next page.

Please send me an invoice to pay by check.

Other

Please select your desired event for your exhibit below?(Required)

Chocolate Tasting Event

Red Shoes Event

Think Pink Event

Winter Wonderland Event

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Please rate the events below based on your preference for your desired featured event.(Required)

Write 1st, 2nd, 3rd or 4th in the boxes below to rate each event by order of preference. This will help us identify which event you would prefer to speak at by your preferred order. Remember, this is a first time first come basis, as such you may not get your first choice. Your local ambassador will contact you and confirm your featured event once it’s been identified.

Chocolate Event

Red Shoes Event

Think Pink Event

Winter Wonderland Event

Please select the name of the ambassador or contact person you're working with below.(Required)

If the name of the contact person is not in the options below, please write their name in the “other” field below.

Other(Required)

Certified Exhibit Quantity (Required)

Please enter a quantity for the total number of events you want to to exhibit.

Price: $2,125.00

Associate Exhibit Quantity (Required)

Please enter a quantity for the total number of events you want to exhibit.

Price: $1,250.00

Are you providing a CE presentation at the event?(Required)

Yes, we will be providing CE for our 50-minutes presentation.

No, but I am bringing a speaker for our 50-minutes presentation

No, we will not use our 50-minutes presentation time. Please find another speaker.

Other

Is the presentation already approved for CE?(Required)

Yes, the course is COPE Accredited by ARBO

Yes, but the course is approved only by the state board

No, the course is not approved for CE, but I already have all the required documents to get the course approve. I will need help.

No the course is not approved for CE and I do not yet have the required documents at this time. I can submit the required documents 6 weeks before the event for submission.

Please enter the course number below.(Required)

CE 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 6 weeks 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.

Speaker BIo

Max. file size: 64 MB.

To help us introduce the speaker at the event, please upload the speaker bio below

Speaker Headshot

Max. file size: 64 MB.

Upload Speaker Picture. This step is not mandatory.

Instructor CV(Required)

Max. file size: 64 MB.

Please upload the instructor CV for COPE accreditation.

Course Outline(Required)

Max. file size: 64 MB.

Please enter course outline below. To qualify for CE credit, the outline must be 2.5 pages long and must include – a course intro summary and learning objectives.

Does the speaker have any Financial Disclosures?

I do not have any relevant financial relationships with any commercial interests for any companies mentioned in my presentation.

I have relevant financial relationships to disclose.

Financial Disclosures(Required)

Please click on the plus (+) sign to the right of the 3rd column to add more rows. 1. List the names of proprietary entities producing health care goods or services, consumed by, or used on patients, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours. 2. Describe what you or your spouse/partner received (ex. Salary, honorarium, royalty, intellectual property rights, consulting fee, ownership interest (e.g. stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. etc). Optometry Divas® does not want to know how much you received. 3. Describe your role. Commercial Interest Nature of Relevant Financial Relationship (include all that apply). What was received for What Role?

Company Name

Role at Company, ex. Speaker

Type of renumeration received, ex. Honorarium

Consent & Logo upload

Logo

If you are providing your logo to us, please upload your company logo below. If you aren’t able to upload the file, please email it to [email protected].

Max. file size: 64 MB.

Consent(Required)

I agree to the terms and conditions below.

GENERAL TERMS AND CONDITIONS

Ensuring the quality of Optometry Divas events for attendees and exhibitors requires a mutual commitment of good faith and cooperation by all parties involved. Except as otherwise agreed in writing, the following General Terms and Conditions are designed to implement the principles of this mutual commitment in a fair, effective, and equitable manner.

CODE OF CONDUCT

Sales and order taking are permitted, provided all transactions are conducted in a manner consistent with the professional nature of the meeting. Products for sale must be the exhibitor’s own unaltered products, and the products or services must be pertinent to the attendees’ professional interest. Optometry Divas reserves the right to restrict sales activities that it deems inappropriate or unprofessional.

LIABILITY & INSURANCE

Exhibitor 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 exhibitor while a participant of 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. exhibitors wishing to insure their marketing 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 Optometry Divas 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 funds collected shall be refunded in full.

PHOTOGRAPHY AND VIDEOTAPING
Photographing, videotaping and/or audio taping of any kind is prohibited during the event without the permission of OPTOMETRY DIVAS. OPTOMETRY DIVAS may engage in photographing, videotaping and/or audio taping the meeting for post meeting promotion and/or educational purposes. Your proprietary presentations will not be recorded.

TERMS AND CONDITIONS COMPLIANCE
The exhibitoring company agrees to abide by all terms and conditions outlined in this agreement. You also agree to share the terms and conditions with your company representatives who attend the OPTOMETRY DIVAS meeting. These terms and conditions may be amended at any time and all amendments, as communicated to and accepted by exhibitor shall be equally binding on all parties affected by them as the original regulations.

Local Event Exhibitor Registration Form

CE courses must be approved by either State Board or ARBO.

Consent & Logo upload

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