Active Minds National Conference 2023 Offline Registration Form

General Information (as you would like to appear on your name tag)

First Name

Last Name

Title (or enter "student" if applicable)

Organization/School Name

Pronouns (If you'd like them included on your name tag)

Is the individual 18 or older?

The target audience for the 2023 conference is young adults, including students (ages 18-25). If you are under the age of 18 and interested in attending the conference please contact Caitlin DeLaurentis at caitlin@activeminds.org for additional information.

Contact Information

Email address

Phone number

Street Address

City

State

Enter "Other" if outside United States

Other State:

Zip

Emergency Contact (First & Last Name)

Emergency Contact Phone #

Conference Details and Preferences

Which conference meals do you plan to attend? (Check all that apply)

Dietary Accommodations

Accessibility

We strive to host inclusive and accessible events that enable all individuals to engage fully. Please include any accessibility services, pursuant to the Americans with Disabilities Act, that Active Minds can provide to the event venue to assist with your experience. If we have any questions an Active Minds staff person will be in contact with you prior to the event.

Please check below to acknowledge the following:

COVID-19 has been declared a global pandemic by the World Health Organization and is extremely contagious. Active Minds will continue to follow applicable protocols to mitigate attendees’ potential exposure to COVID-19; however, Active Minds cannot guarantee that attendees will not become infected with COVID-19. By registering for the Active Minds 2023 Mental Health Conference, I

-Acknowledge the contagious nature of COVID-19;
-Voluntarily assume the risk that I may be exposed to or infected by COVID-19 by attending the Active Minds Conference which exposure or infection may come from the actions, omissions, or negligence of myself and others, including, but not limited to, Active Minds employees, volunteers, and program participants and their families;
-Acknowledge that such exposure or infection may result in personal injury, illness, permanent disability, and death; and
-Hereby release, covenant not to sue, discharge, and hold harmless Active Minds, its employees, agents, and representatives, of and from any injury to me resulting from being exposed to or infected by COVID-19 in connection with my attendance at the Active Minds Conference (including claims based on the actions, omissions, or negligence of Active Minds, its employees, agents, and representatives).

Acknowledged

Presenter?

Opportunity ID

Active Minds 2023 Mental Health Conference Registration Form