Florida School Nutrition Association

/ Florida School Nutrition Association
Region IV Seminar
Registration Form
Date: / October 22, 2016 / Time of Registration: / 7:30-8:15 am
Location: / St. Cloud High School
2000 Bulldog Lane
St. Cloud, Florida 34769 / Hotel Suggestion:
/ Budget Inn of St. Cloud
602 13th Street(Hwy 195-441)
St. Cloud, FL 34769
(407) 892-2858
Registration Fee:
Theme: / Pre Conference: $20.00
On Site: $25.00
Helping People Climb The Ladder of Life / Pre-Registration Due:
Chapter Tables: / September 23, 2016
$10.00

Local Associations are asked to register as a group. Please submit individual registration forms and checks made payable to your local association. Your local association in turn will submit all registration forms and one check payable to Rita Lewis to cover all registration fees to: 640 Sea Gull Dr., Satellite Beach, FL 32937

Continental Breakfast

Great Educational Sessions

Lunch

Door prizes

Drawing for either a Limited Annual Conference Registration or Legislative Action Caucus Registration

Name: ______County: ______

Address: ______

City, State, Zip: ______

Phone number ______

Is this your first Region Seminar? Yes ___ No ____ Are you a member of FSNA? Yes___ No_____

Would you like to reserve a Sales Table for your Chapter? Yes ___ No ___

FSNA is committed to ensuring all meeting activities are accessible. To discuss specific needs, including dietary, contact your Region Director on or before October 8, Daytime Telephone: 321-794-0472; Email:

LIABILITY AND INDEMNIFICATION AGREEMENT

I request that you accept me as a participant at the Florida School Nutrition Association (FSNA) Region Seminar. I understand there is some risk inherent in traveling to and from, and as a result of, attending the Seminar. The undersigned hereby releases the FSNA and the committees, members, officers, employees, as well as other participants and other persons who may take part in said seminar from all liability for injury, death and property damage that may be suffered in connection with such activities, where due to negligence or otherwise, accepting such risks involved and waiving all rights of any kind that might otherwise arise. The undersigned agrees to indemnify FSNA, its committees, members, officers, employees, and director against all judgments obtained and against the cost of defense of such claims including reasonable attorney’s fees.

Signature Required for Registration: ______

(If sending in the group registration form below, have each registrant sign below his or her name on the registrant list as indicated. Each registrant must sign below their name if you are using the group registration form. If using the group registration form, you do not have to send in this separate form for each registrant.)

Florida School Nutrition Association

Region IV Seminar

CHAPTER GROUP Registration Form

Local Associations are asked to register as a group. In lieu of submitting individual registration forms please list all attendees from your district and submit with one check payable to Rita Lewis to cover all registration fees to: 640 Sea Gull Dr., Satellite Beach, FL 32937

Chapter: ______

Contact Person for this Registration List______

Phone Number: ______

Email Address: ______

Chapter Sales Table Requested? ______

LIABILITY AND INDEMNIFICATION AGREEMENT

By registering and signing below your name you are agreeing to the above Liability and Indemnification Agreement above. Your signature below your name is REQUIRED for Registration.

Name-Please Print and then sign below name / Address, City, State, Zip / Phone # / 1st Region Seminar? / FSNA Member?
1. / Yes or No / Yes or No
2. / Yes or No / Yes or No
3. / Yes or No / Yes or No
4. / Yes or No / Yes or No
5. / Yes or No / Yes or No

LIABILITY AND INDEMNIFICATION AGREEMENT

By registering and signing below your name you are agreeing to the above Liability and Indemnification Agreement above. Your signature below your name is REQUIRED for Registration.

Name-Please Print and then sign below name / Address, City, State, Zip / Phone # / 1st Region Seminar? / FSNA Member?
6. / Yes or No / Yes or No
7. / Yes or No / Yes or No
8. / Yes or No / Yes or No
9. / Yes or No / Yes or No
10. / Yes or No / Yes or No
11. / Yes or No / Yes or No
12. / Yes or No / Yes or No
13. / Yes or No / Yes or No

LIABILITY AND INDEMNIFICATION AGREEMENT

By registering and signing below your name you are agreeing to the above Liability and Indemnification Agreement above. Your signature below your name is REQUIRED for Registration.

Name-Please Print and then sign below name / Address, City, State, Zip / Phone # / 1st Region Seminar? / FSNA Member?
14. / Yes or No / Yes or No
15. / Yes or No / Yes or No
16. / Yes or No / Yes or No
17. / Yes or No / Yes or No
18. / Yes or No / Yes or No
19. / Yes or No / Yes or No
20. / Yes or No / Yes or No
21. / Yes or No / Yes or No