NC2022 Registration for Speakers & Presenters Step 1 of 5 20% IntroductionDear NC2022 Presenter, We are excited to invite you to the 50th Anniversary Celebration of the first Chapter of the Latino Medical Student Association (LMSA), founded in 1972. Thank you for being an important part of the LMSA's history and continued success. Information on the 2022 LMSA National Conference and each of its events can be found at http://lmsa.me/NC2022. Please use this form to register for the event (or to submit registration information on behalf of another individual). This form must be completed to secure your spot in NC2022 programming. Please note: complimentary registration is provided to speakers and moderators specifically for the session(s) in which they will be presenting. Additional registration (with payment) is required to partake in other sessions. (Example: a workshop presenter for NC2022 interested in participating in LIDEReS must register and pay for LIDEReS.) Questions about this may be directed to email@example.com.This form is able to securely collect payment information as needed using credit/debit card. All paid registrations are subject to a 3% payment processing fee to help LMSA offset costs associated with credit/debit card payments. For any questions regarding this form, the 2022 LMSA National Conference, or the National Center, please reach out to firstname.lastname@example.org. We look forward to hosting you in March 2022. Please click "Next" to proceed with the registration form. Registrant InformationEarly Reg End Date MM slash DD slash YYYY Date(Required) MM slash DD slash YYYY Are you registering a speaker or moderator? (Yourself or someone else)(Required) Yes No Please use the NC2022 Registration for Professional Attendees form to register as an attendee. This form is for speakers and moderators only. DO NOT PROCEED WITH THIS FORM.Please indicate the registrant's role(s) in the 2022 LMSA National Conference.(Required) LIDEReS Speaker LIDEReS Moderator LISTOS Speaker LISTOS Moderator NC2022 Keynote Speaker NC2022 Workshop Presenter Please provide information for the form respondent - the individual completing this form - wherever it says "Contact Person."Contact Person Name(Required) Dr.Mr.Mrs.Ms.Prof.Dean Prefix First Last Suffix Contact Person Email Address(Required) Contact Person Phone Number(Required)Institution / Organization / Affiliation(Required) Billing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country A billing address is required for all registrations, including free / complimentary orders.Are you registering on behalf of someone else?(Required) Yes No Please select "No" if the person completing this form is also the person to be registered.Registrant's Name(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Suffix Registrant's Email Address(Required) Registrant's Phone Number(Required)Registrant's Professional Title(Required) Presenter's Headshot(Required)Max. file size: 10 MB.Please upload an image file of the speaker or presenter's headshot here. This image will be featured in the conference program booklet.Presenter's Biographical Statement(Required)Max. file size: 10 MB.Please upload a text file of the speaker or presenter's bio here. This will be featured in the conference program booklet. Will the registrant be participating virtually or in person?(Required) In-Person Virtual Is the registrant interested in participating in other portions of the NC2022 program?(Required) Yes No Complimentary registration is provided to speakers and moderators specifically for the session(s) in which they will be presenting. Additional registration (with payment) is required to partake in other sessions. (Example: a workshop presenter for NC2022 interested in participating in LIDEReS must register and pay for LIDEReS.) Questions about this may be directed to email@example.com.For In-Person LIDEReS Presenters: click below to register for the rest of the 2022 National Conference. 50th Anniversary Package ($400) Note: The 50th Anniversary Package grants access to all NC2022 activities on March 4-5, 2022. These include faculty & alumni workshop tracks on both days, LISTOS, the PODER Research Symposium, and the NC2022 Closing Ceremony.For In-Person LISTOS Presenters: please select additional NC2022 programming below. 50th Anniversary Package WITH LIDEReS ($550 with presenter discount) 50th Anniversary Package Only ($200 with presenter discount) LIDEReS Only ($500) Note: The 50th Anniversary Package grants access to all NC2022 activities on March 4-5, 2022. These include faculty & alumni workshop tracks on both days, LISTOS, the PODER Research Symposium, and the NC2022 Closing Ceremony.For In-Person NC2022 Presenters: would you like to register for LIDEReS? LIDEReS Only ($500) For Virtual LIDEReS Presenters: click below to also register as a virtual attendee for LISTOS. Virtual LISTOS ($125) If you are planning to present virtually for LIDERes but attend LISTOS and/or NC2022 in person, please contact firstname.lastname@example.org before proceeding with this form.For Virtual LISTOS Presenters: click below to also register as a virtual attendee for LIDEReS. Virtual LIDEReS ($300) If you are planning to present virtually for LISTOS but attend LIDEReS and/or NC2022 in person, please contact email@example.com before proceeding with this form.Virtual NC2022 Presenters interested in registering for other NC2022 programming for Professional Attendees must complete the Professional Attendee Registration Form. I understand. https://national.lmsa.net/programming/nc2022/prof-reg/In-Person Early Bird Discount $0.00 Virtual Early Bird Discount $0.00 Please proceed to the next page to answer additional attendee questions, as applicable. The payment step can be found on the page that follows. Questions for In-Person AttendeesDesired Name on Attendee Badge(Required) Please include prefix and suffix as desired.Pronouns(Required) He/him/his She/her/hers They/them/theirs Other All registrants will have pronouns printed on their attendee badges.Any allergies or dietary restrictions?(Required) Yes No Please specify dietary restrictions below:(Required)Final Registration QuestionsAccommodationsPlease let us know if you require any form of assistance or special accommodations to participate in LMSA programming.Any questions or comments for the event organizers? Registration Terms & CheckoutAll form respondents are asked to review and accept the Terms & Conditions stated below. Notably, all in-person attendees for the 2022 LMSA National Conference are asked to provide proof of vaccination against COVID-19. Professional registrants will have a chance to upload a picture of their CDC COVID-19 Vaccination Card to their pre-event survey form. They will also be able to show their registration card at time of check-in. However, no refunds will be issued to those who arrive on-site but are denied entry for failing to comply with this requirement. Any questions or concerns regarding this policy may be directed to Dr. JP Sánchez at firstname.lastname@example.org.LMSA Event Registration Terms & Conditions(Required)This section sets out the terms and conditions between The Latino Medical Association (aka “LMSA” and “LMSA National”) and you when you register for any event or conference organized by LMSA. By registering for an event or conference organized by LMSA you are agreeing to comply with these terms and conditions. Please read this section carefully. The following LMSA Registration Terms & Conditions (the “Terms & Conditions”) apply to all LMSA events. Prior to your registration, you must acknowledge and accept the Terms & Conditions contained herein. Should you not wish to accept the Terms & Conditions, you should not register. Submission of a registration is regarded as affirmation of your acceptance of the Event Terms & Conditions. Nondiscrimination Policy LMSA is committed to providing a safe, productive, and welcoming environment to all LMSA event participants. LMSA has no tolerance for discrimination, harassment, or bullying in any form at any LMSA event. Participants are expected to adhere to these principles and respect the rights of others. Specifically, LMSA prohibits discrimination, harassment, and bullying against any person for any reason—for example, because of age, ancestry, color, disability or handicap, national origin, race, religion, gender, sexual or affectional orientation, gender identity, appearance, matriculation, political affiliation, marital status, veteran status, or any other characteristic protected by law. Any event registrant or attendee who engages in discriminatory behavior against any other registrant or attendee shall be removed from the event and prevented from joining future LMSA events at the discretion of the LMSA National leadership or its designated representative(s). Participants should report any behavior inconsistent with the principles above to LMSA event organizers or LMSA National leaders. These individuals will be happy to assist those experiencing harassment to feel safe for the duration of the event. Data Use The personal information supplied in connection with this registration will be held by LMSA as a record of attendees and parties expressing interest. By registering for this event, you agree that LMSA and its event organizers may use your personal information to contact you by email, direct mail, or telephone in order to supply information relevant to this conference, or about other LMSA conferences, events and opportunities. LMSA may also share your information with its partners and event sponsors in order for them to contact you about other products and services which may be of interest. If you do not want your details to be used in this way, please email email@example.com. Photo/Video Release By registering and attending this LMSA event, you allow LMSA to use any photographs and/or video recordings that include your image, likeness, voice, or other materials derived from you and your involvement in this event. You further acknowledge that such media may be used for LMSA marketing and promotional activities, including, but not limited to, features on LMSA social media channels, newsletter, and other outlets. Lastly, LMSA disclaims all liability for the capture of your image in any multimedia format by other attendees at the event. Liability Waiver In consideration of being allowed to register for, and participate in the event, you hereby warrant and represent that you are age 18 or above, or you have the approval of a parent or legal guardian. Additionally, you freely waive, release from liability, assume all risks, and covenant not to sue LMSA or its members, employees, board members, agents, or volunteers for any expense, loss, damage, personal injury, including loss of life, illness, disability, property damage, or property theft or actions of any kind that you may hereafter suffer or sustain before, during, or after the event, to the extent permissible by law. LMSA is in no way responsible for technical difficulties, outages, or other impediments preventing attendees from accessing the event location and/or platform. This Liability Waiver and Release is specifically binding upon your heirs and assigns and is knowingly given. Cancellation, Refund & Substitution Policy You are entitled to cancel your registration at any time prior to the start of the event. Refunds, minus any payment processing fees, may be issued only for registrations made at least THIRTY (30) days prior to the start of the event. If you cancel your registration within THIRTY (30) days of the event start date, you will forfeit 100% of your registration fee. All refunds will be made after the event, within TWO (2) months of the event end date. Based on the above, refunds for NC2022 registrations may be issued only for cancellation requests made by 11:59pm Pacific Time on February 1, 2022. If you cancel your registration after this deadline, you will forfeit all registration fees paid. Substitutions (i.e. registration transfers from one person to another) may be made at any time. If you wish to substitute a participant, please contact firstname.lastname@example.org as soon as possible. The new registrant will be subject to additional fees if the substitution occurs during a registration period other than the registration period that was active when the original registration was made. NC2022-Specific Provisions Participants for the 2022 LMSA National Conference (NC2022) are expected to adhere to these Terms & Conditions, as well as any additional rules and regulations set forth by LMSA event organizers, regardless of whether participants participate in NC2022 programming virtually or in person. All in-person attendees must comply with additional health and safety requirements in place for NC2022. In particular, all in-person attendees must provide proof of vaccination against COVID-19. Attendees are strongly encouraged to upload an image of their Centers of Disease Control & Prevention (CDC) COVID-19 Vaccination Card to their pre-event survey. Alternatively, attendees may provide proof of vaccination at time of check-in. Universal masking will be required throughout NC2022, unless otherwise directed by federal, state, or local authorities. Symptomatic individuals will not be allowed entry to in-person conference events. LMSA reserves the right to refuse entry to or remove individuals who do not comply with these requirements. In-person attendees who are removed or refused entry due to failure to adhere to NC2022 health and safety requirements shall NOT receive any refund for event registration fees. Terms & Conditions specifically for NC2022 Sponsors & Exhibitors can be found in the NC2022 Sponsor & Exhibitor Prospectus. General LMSA reserves the right to change, amend, add or remove any of the above Terms & Conditions in its sole discretion and without prior notice. If one or more of the conditions outlined in these Terms & Conditions should become invalid, the remaining conditions will continue to be valid and apply. These Terms & Conditions apply to all event participants (attendees, speakers, sponsors, exhibitors). Additionally, LMSA reserves the right to make alterations to the conference program and/or timings at any time. In the event of it being found necessary, for whatever reason, to postpone the event, change the event format, or change event dates, neither LMSA nor the event organizers shall be liable for any expenditure, damage or loss incurred by any attendee. If by re-arrangement or postponement the event can take place, the attendee’s registration shall remain in force and will be subject to the cancellation policy above unless otherwise determined by LMSA. Lastly, the views expressed by any event attendee, speaker, exhibitor, or sponsor are not necessarily those of LMSA. All attendees, speakers, exhibitors, and sponsors are solely responsible for the content of all individual or corporation presentations, marketing collateral, and/or advertising. I agree to the Terms & Conditions. FOR LMSA STAFF USE ONLY: ADJUSTMENTS The total for your order is shown below. If this value is equal to $0, you will not be asked for billing information below.Payment Processing Fee $0.00 With the exception of free orders, all registrations are subject to a 3% payment processing fee. This allows LMSA to offset costs associated with credit/debit card payments. Questions regarding this fee may be directed to email@example.com.Total With the exception of free orders, all registrations are subject to a 3% payment processing fee. This allows LMSA to offset costs associated with credit/debit card payments. Questions regarding this fee may be directed to firstname.lastname@example.org.Credit Card(Required)Card Details Cardholder Name This is a free order. Please make sure to hit "Submit" below to finalize your registration.