Event Registration Form Event Registration 2nd Annual Leadership Conference - Virtual & Live Lead from Where You Are on Friday, April 16, 2021First Name*Last Name*Email Address* Phone Number*Title/Rank*College/Department/Unit*School*SelectAnderson University, Inc.Ball State UniversityButler UniversityChristian Theological SeminaryConference Guest SpeakerDePauw UniversityEarlham CollegeGoshen CollegeIndiana University EastIndiana University KokomoIndiana University NorthwestIndiana University South BendIndiana Wesleyan UniversityPurdue UniversityRose-Hulman Institute of TechnologySaint Mary-Of-The-Woods CollegeValparaiso UniversityVincennes UniversityWabash CollegeProduct Name* Price: $20.00 Not affiliated with a member school listed above. Not affiliated with a member school listed above. *If this box is selected you will receive an invoice for $20 by email.Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Additional QuestionsWhat is your area of expertise/discipline?*Would you like your name, discipline, and email listed in a networking list which will be emailed to participants after the conference?*YesNoWould you have interest in networking virtually with other attendees during the conference?*YesNoPlease select which of the following sessions you plan to attend on April 16, 2021:* Keynote with Ashleigh Shelby Rosette Talk with ACE President Ted Mitchell Concurrent Breakout Sessions (please select one of the following):*The Courage to Lead: Inner Dimensions of LeadershipHow to Mentor and Support Other WomenHow did you hear about the Women’s Network of Indiana Annual Leadership Conference?*What brings you to a conference for leadership?*If you have attended the Women’s Network of Indiana Annual Leadership Conference previously, what brings you back?*Would you like to be added to the mailing list of the ACE-Women’s Network of Indiana?*YesNoEmail* Consent* By checking this box, I attest that I have read this policy and agree to follow it.*Registrants will receive the link to access the virtual live conference and this will be strictly monitored. Please indicate the login/username/full name you will use to access the virtual conference link.Liability Waiver:All Participants Are Asked to Consent To: By registering for the 2021 ACE-WN-IN leadership conference, I agree and acknowledge that I am undertaking participation in these events and activities as my own free and intentional act and I am fully aware that possible physical injury might occur to me as a result of my participation in these events. I give this acknowledgement freely and knowingly and that I am, as a result, able to participate in the conference and I do hereby assume responsibility for my own well-being. I also agree not to allow any other individual to participate in my place.Permission for Recording and Social Media Use All Participants Are Asked to Consent To: The ACE-WN-IN, through itself or its contractors, may record all or portions of the events and functions at the ACE Women's Network of Indiana Leadership Conference, including through audio and video recording and photography, for the production of material distributed for a variety of purposes, including but not limited to educational, archival, or promotional purposes. By registering, you irrevocably grant the American Council on Education Women's Network of Indiana, its assignees and licensees permission to capture your image through photography, video, or any other means, and record your voice at any time and anywhere throughout the conference.If you would like to decline permission for the ACE-WN-IN to include you in any recorded material, you can request, in writing to [email protected], to be excluded and the ACE-WN-IN will make a good faith effort to remove you from any of the material that is published or otherwise publicly shared for promotional or educational purposes.I give consent for ACE-WN-IN to take my photo/video during the program for publicity and/or research purposes only.ReCaptchaPhoneThis field is for validation purposes and should be left unchanged.
