The The Chicago Marriott Downtown - Magnificent Mile · Chicago, IL 
NBNA 33rd Annual Institute and Conference

Speaker Consent Form

Producer: _____________________________

Location: ______________________________


I hereby agree to your recording, videotaping and publicly exhibiting my appearance and/or participation at your Annual Institute and Conference Workshop and/or Session Program entitled: ____________________________________________
_____________________________________________________________________ (the Program),
and in consideration of the mutual benefits flowing from such exhibition, I agree as follows:

  1. You are the sole owner of all rights in and to the Program and its content and recordings for all purposes and uses of any type including, without limitation, the following rights which you may, in your sole discretion, exercise throughout the world and forever: (a) to publicly exhibit, distribute and/or license others to publicly exhibit or distribute the Program, and any part(s) or edited version of the Program, one or more times by any means of transmission now or hereafter known (including, but not limited to broadcast by television stations, origination or dissemination on cable TV systems, distribution in the form of videocassettes, or direct projection before audiences), in therefore or whether the exhibition is on a commercial and/or non-commercial basis: (b) to publish, disseminate and edit the text of the Program in any form, and (c) to assign all or part of any such right to others.

  2. You shall have the right to use and license others to use my name, likeness and biographical material as I may furnish in connection with advertising and/or publicizing the National Black Nurses Association, your agents, your licenses, the Program ("Advertisers") and their products or services, but not, however, as an endorsement.

  3. By signing this agreement I am releasing you, your agents, Officers and Advertisers from and against claims of any nature arising from reason of my appearance and/or participation in the Program, statements made by others in, or in connection with, the Program, or your exercise of the rights which I have granted you in this agreement.

  4. I agree to indemnify and hold harmless, you, your agents, Officers and Advertisers and you and their officers, directors, agents and employees from and against any and all claims, damages, liabilities, costs and expenses (including consul fees) arising from the recording, videotaping or other publication of

Your permitting me to appear in the Program shall constitute your approval of this agreement.

Date: _______________________

Print Name: _______________________________________________________________

Signature: ________________________________________________________________

Address: _________________________________________________________________

City/State/Zip: _____________________________________________________________

 

 

Disclosure Statement


Disclosure of any significant financial interest or other affiliation a presenter has with a commercial supporter of the educational presentation, and/or the manufacturer of any commercial products discussed in the educational presentation is requested. The existence of such relationships does not necessarily constitute a conflict of interest, but the audience must be informed of such affiliation of the presenter by way of acknowledgement in the printed program. Disclosure should be provided for the relationships or circumstances that might reasonably by expected to influence the presenter's view on the topic.

Each participant (including directors, chairpersons, moderators, discussants) must return a completed disclosure statement with the submission form or the submission will not be considered. It is the responsibility of the submitting individual to circulate and collect disclosure statements from all co-presenters to be included with the submission. Non-participating co-authors Poster Submissions are not required to submit a disclosure statement. Photocopy this form as needed.

Name (printed/typed): _______________________________________________________________

Signature: ________________________________________________________________________

Date: ____________________________________________________________________________

Commercial Affiliation and Relationship: ________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

   PLEASE SUBMIT MATERIALS TO:
Dianne Mance, Conference Services Coordinator
National Black Nurses Association
8630 Fenton Street, Suite 330, Silver Spring, MD 20910
Fax: (301) 589-3223
   
Click here for Call for Abstracts
Click here for Abstract Submission Form  •  Click here for A / V Checklist Form
Click here for Speaker Registration Form  •  Click here for Speaker Consent Form
Click here for Speaker/Presenter Objectives & Content Outline