Award Recipients

Excellence in Resuscitation Award Recipients

Prefix
First Name*
Last Name*
Email*
Do you plan to attend the event in person?*
If no, please provide your mailing address.
What is the best phone number to reach you on?*
Are you bringing a guest?*
If yes, what is their first and last name?
Do you or your guest have any dietary restrictions?*
If yes, please specify.
Are you AHS Direct Delivery?*
If no, what service do you work for?
Do you have an AHS dress uniform?*
If yes, does your uniform require alterations?
If no, have you been fitted and where were you fitted?
What zone do you currently work in?*
What is the name of your supervisor?

Consent to photography/videography · I authorize the organizing committee to record me and/or take my photo and use them in communications about the Excellence in Resuscitation Ceremony. I understand there are many ways of sharing communication, including printed and electronic methods. I understand that the recording or photo may be shared with a range of people and groups. · I understand why these recordings and/or photos are being taken and how they may be used. I know that there are risks and benefits to giving this consent. I know that I can stop this consent at any time by informing the organizing committee in writing. · I understand that the organizing committee cannot control information once it has been shared in public. I understand that if I ask the organizing committee to stop using my recordings and/or photos it will only stop additional use of those recordings and/or photos after the date my request is received. · I agree to release and discharge the organizing committee from the responsibility and liability of the content and claims for the printed/electronic communication where my information was used. I confirm that this release and discharge shall be binding upon my heirs, executors, administrators, and assigns. · The consent will be effective Oct 16, 2024. We will also be using photos and information from this year for next year’s advertising.
Consent*

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