Patient Panelist Interest for EOS Connection

What is your relationship to eosinophil-associated diseases? Please select all that apply.

Please indicate what eosinophil-associated disease(s) you are impacted by.

EOS Connection, APFED’s Annual Patient Education Conference, (and related events, including miscellaneous social and gaming activities; collectively, the “Event”) is a charity event sponsored by the American Partnership for Eosinophilic Disorders (“APFED”). In consideration of APFED permitting me (or my child, who is under the age of 18) to participate in the Event, I have read and understand this statement and agree to assume all risk for personal injury or other physical or emotional ailment for me (or my child). Further, I (or my child) hereby, and for my (or my child’s) legal representatives, heirs, executors, administrators, assigns, and all guardians, WAIVE, RELEASE AND DISCHARGE ANY AND ALL RIGHTS, CLAIMS AND CAUSES OF ACTION OF ANY NATURE, DIRECT OR INDIRECT, INCLUDING THOSE FOUNDED IN WHOLE OR PART UPON NEGLIGENCE, that I (or my child) may have against APFED and/or its collective sponsors, its directors, officers, employees, agents, chapters, assignees, licensees, volunteers and any cooperating entities, their representatives, heirs, executors, administrators, successors, and assigns (the “Released Parties”) arising out of or resulting from any and all injuries or damages of any nature, including death, which I (or my child) may suffer while taking part in or arising out of the Event or any activity connected with the Event. Photo Waiver For Onsite Attendees Only: If I (or my child) attend the conference in person, I (or my child) hereby consent to use my (or my child’s) name and any photographs, digital images, portraits, likenesses, writings or biographical information, audiotape and/or videotape recordings, sound or silent motion pictures of me (or my child) in any medium for news releases, use on the APFED website, editorial, educational, promotional, and advertising purposes, for the solicitation of contributions and/or for any other purpose in furtherance of the charitable purposes and objectives of APFED. I understand that I may opt out of this photo waiver by requesting a special NO PHOTO badge onsite at the conference registration desk and will agree to wear a special badge at all times to indicate to photographers that I do not want to be photographed. By registering for this conference, I certify that I have read these terms and fully understand them. This agreement shall be binding upon me (or my child), my (or my child’s) legal representatives, heirs, executors, administrators, and assigns (and all legal guardians of my child).