Sponsorship Registration 2022 Event Sponsorship Registration Form Please complete this form to register as a sponsor for our events. The information collected on this form will be used for internal administrative purposes only. Date(Required) MM slash DD slash YYYY 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best Phone Number to Reach The Representative(Required)Representative Email(Required) What are your top 1-3 reasons for sponsoring our events?(Required)Your answers to this question will help us create a world-class experience for you as well.Company/Brand/Product AwarenessLead GenerationBuild PartnershipsSee Current ClientsNetworkingTo support the organizationTo make salesOther - Please describe belowHow can we best help you get a successful outcome?(Required)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 goals at this event?Which category of ODs is your ideal prospect?(Required) Private Practice Owners Private Practice Associates Corporate Lease Owners Corporate Lease Associates Independent Contractors Ophthalmology Group Associates Any Practicing Optometrist Do you want to sign up for the multiple event bundle option?(Required) Yes No Please list the events you want to sponsor 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.CityAmbassador NameEvent ThemeEvent Date Add RemoveIn what city and state is event that you are sponsoring?(Required)For virtual events, please type virtual as the city and chose FL as the state. City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State HiddenIn 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. CityState Add RemoveWhich event 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. Chocolate Tasting Event Red Shoes Event Think Pink Event Winter Wonderland Event Other HiddenWhich 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. Chocolate Tasting EventRed Shoes EventThink Pink EventWinter Wonderland EventCEO of You EventOtherHiddenOther(Required) 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. Dr. Glenda Aleman - Miami, FLDr. Michelle Gonzalez - Miami, FLDr. Kristie Nguyen - Orlando, FLDr. Samantha Love - Orlando, FLDr. Christine Manzella - Tampa, FLDr. Kate Maloney - Fort Myers, FLDr. Nataliya Yakovleva - Jacksonville, FLDr. Kerri-Ann Hodge - Houston, TXDr. Ashley Hemmati - Houston, TXDr. Lachionte Culpepper - Atlanta, GADr. Meron Fantahun - Atlanta, GADr. Lisa Hornick - Sacramento, CADr. Linh Ngo - Sacramento, CADr. Diana Canto-Sims - Chicago, ILDr. Faye Gamboa - Chicago, ILDr. Artee Nanji - Memphis, TNDr. Erika Cox - Memphis, TNDr. Sally Mina - Dallas, TXDr. Alyssa Pack - San Diego, CADr. Beverly Bianes - San Diego, CADr. Lauretta Justin - FounderOtherOther(Required) Which level are you sponsoring?(Required)If the sponsorship option you established with one of our ambassadors is not listed below, please document the option discussed in the "other" field. For additional assistance, please email us at [email protected] Certified Sponsorship Level - $2500 Associate Sponsorship Level - $1500 Other Certified Sponsorship Quantity(Required)Please enter a quantity for the total number of events you want to sponsor. Price: $2,125.00 Quantity: Associate Sponsorship Quantity(Required)Please enter a quantity for the total number of events you want to sponsor. Price: $1,250.00 Quantity: Are you providing a CE presentation at the event?(Required) Yes No 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 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 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.Speaker BIo(Required)Max. file size: 64 MB.To help us introduce the speaker at the event, please upload the speaker bio belowSpeaker HeadshotMax. 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.Consent & Logo uploadLogoIf 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 sponsors 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 Sponsor’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 Sponsor 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 Sponsor 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. Sponsors 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 sponsoring 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 sponsor shall be equally binding on all parties affected by them as the original regulations.