2022 AMA Leadership Summit - Guest Speaker Questionnaire (In-Person)

Name(Required)

First Last

Email Address(Required)

Phone(Required)

A personalized verification code will be sent to this mobile number granting access to the Leadership Summit virtual platform. Add a country code with the + if outside of the US and Canada (e.g., +4911111111).

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company/Organization(Required)

Job Title(Required)

Number of Employees(Required)

Industry(Required)

Do you have dietary restrictions and/or require accessibility accommodations?

Yes

Please specify the nature of your dietary restrictions/requested accessibility accommodations.

COVID-19 Vaccination Requirement

In order to provide a safe environment for employees, volunteers, and guests, the AMA requires self-certification of vaccination prior to attending a live event or meeting.

COVID-19 Safety Acknowledgment and Self-Certification(Required)

COVID-19 Safety Acknowledgment —
Liability Waiver and Release of Claims

COVID-19 SAFETY INFORMATION:

While participating in events held or sponsored by the American Marketing
Association, (“AMA”), consistent with CDC and WHO guidelines, participants are encouraged to practice hand hygiene, “social distancing”, and wear face coverings to reduce the risks of exposure to COVID-19. Because COVID-19 is extremely contagious and is spread mainly from person-to-person contact, AMA has put in place preventative measures to reduce the spread of COVID-19. However, AMA cannot guarantee that its participants, volunteers, partners, or others in attendance will not become infected with COVID-19.

In light of the ongoing spread of COVID-19, individuals who fall within any of the categories below should not engage in AMA events and/or other face to face activities. By attending an AMA event, you certify that you do not fall into any of the following categories:

Individuals who currently or within the past fourteen (14) days have experienced any symptoms associated with COVID-19, which include fever, cough, and shortness of breath among others;

Individuals who believe that they may have been exposed to a confirmed or suspected case of COVID-19 or have been diagnosed with COVID-19 and are not yet cleared as non-contagious by state or local public health authorities or the health care team responsible for their treatment.

DUTY TO SELF-MONITOR:

Participants and volunteers agree to self-monitor for signs and symptoms of COVID-19 (symptoms typically include fever, cough, and shortness of breath) and, contact AMA at customersupport@ama.org or 1-800-AMA-1150 if they experience symptoms of COVID-19 within 14 days after participating or volunteering with AMA.

LIABILITY WAIVER AND RELEASE OF CLAIMS:

I acknowledge that I derive personal satisfaction and a benefit by virtue of my participation and/or volunteerism with AMA, and I willingly engage in AMA events and/or other activities (the “Activity”).

I also acknowledge that in a pandemic like COVID-19, public health regulations evolve rapidly. The AMA will do its best to have in place and keep participants apprised of appropriate safety measures, but the ultimate responsibility to keep yourself safe lies with each individual. I promise to follow all health and safety guidelines provided by the venue and AMA, including mask wearing.

RELEASE AND WAIVER.

I HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE ANY AND ALL
LIABILITY, CLAIMS, AND DEMANDS OF WHATEVER KIND OR NATURE
AGAINST THE AMERICAN MARKETING ASSOCIATION AND ITS AFFILIATED
PARTNERS AND SPONSORS, INCLUDING IN EACH CASE, WITHOUT
LIMITATION, THEIR DIRECTORS, OFFICERS, EMPLOYEES, VOLUNTEERS, AND AGENTS (THE “RELEASED PARTIES”), EITHER IN LAW OR IN EQUITY, TO THE FULLEST EXTENT PERMISSIBLE BY LAW, INCLUDING BUT NOT
LIMITED TO DAMAGES OR LOSSES CAUSED BY THE NEGLIGENCE, FAULT
OR CONDUCT OF ANY KIND ON THE PART OF THE RELEASED PARTIES,
INCLUDING BUT NOT LIMITED TO DEATH, BODILY INJURY, ILLNESS,
ECONOMIC LOSS OR OUT OF POCKET EXPENSES, OR LOSS OR DAMAGE
TO PROPERTY, WHICH I, MY HEIRS, ASSIGNEES, NEXT OF KIN AND/OR
LEGALLY APPOINTED OR DESIGNATED REPRESENTATIVES, MAY HAVE
OR WHICH MAY HEREINAFTER ACCRUE ON MY BEHALF, WHICH ARISE OR MAY HEREAFTER ARISE FROM MY PARTICIPATION WITH THE ACTIVITY.

ASSUMPTION OF THE RISK.

I acknowledge and understand the following:

Participation includes possible exposure to and illness from infectious diseases including but not limited to COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist;

I knowingly and freely assume all such risks related to illness and infectious diseases, such as COVID-19, even if arising from the negligence or fault of the Released Parties; and

I promise to follow all health and safety guidelines provided by the venue and AMA, including mask wearing; and

I hereby knowingly assume the risk of injury, harm and loss associated with the Activity, including any injury, harm and loss caused by the negligence, fault or conduct of any kind on the part of the Released Parties.

BY REGISTERING FOR, ATTENDING, OR PARTICIPATING IN THE ACTIVITY, YOU ARE DEEMED TO HAVE GIVEN A FULL RELEASE OF LIABILITY TO THE RELEASED PARTIES TO THE FULLEST EXTENT PERMITTED BY LAW.

By submitting this form, you confirm to have read and agree to the terms listed in the COVID-19 Safety Acknowledgement, and certify to be fully vaccinated against COVID-19 or will be fully vaccinated by the event date according to CDC or WHO standards published at https://www.cdc.gov/coronavirus/2019ncov/vaccines/fullyvaccinated.html or https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines/advice

COVID-19 Vaccination Requirement

Data Sharing