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MMRP ECHO Across Washington registration

Please complete the registration form below.

Please click the green "Add signature" icon to sign the Personal Release form as we will be videotaping the meeting.

Thank you!

Attendee First Name

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Attendee Last Name

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Professional Degree(s)

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Attendee Organization - Name

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Attendee Organization - Zipcode

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Email Address

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The MMRP ECHO Across Washington sessions will be an opportunity for regional clinicians, staff, etc. to come together for an introduction to the 2023 MMRP Report to the Legislature and to facilitate some relevant clinical discussions. Representatives from the University of Washington and the Washington State Department of Health (DOH) will present. We hope you can join us in person.

Session(s) you wish to attend.

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Yakima, May 1

SeaTac, OB COAP annual meeting, June 8

Spokane, May 30

Tacoma, TBD (virtual session)

Olympic Peninsula, TBD

Omak, TBD

Vancouver, June 28

Native Maternal Mortality Townhall, June 13

July 20, Kitsap Maternal Infant Health Forum, Bremerton (registration required: https://Kitsap-MIH-Forum.eventbrite.com)

Not all sessions will be available virtually. Do you plan to attend an in-person or online session of MMRP ECHO Across Washington?

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In person

Online (Zoom)

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Box lunches (dinner) will be provided at the event. Shall we order one for you?

Yes

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Please select one.

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Sandwich

Salad

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Please list any dietary restrictions.

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The University of Washington (UW) will have a videographer on site at the in-person event. Attendees must have a personal release on file. The release asks for your address and telephone number. Please complete all fields.
Thank you so much.
-MMRP ECHO Team

Your street address

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Your Zipcode

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Your phone number

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PERSONAL RELEASE

I hereby grant permission to the University of Washington (UW) and its assigns and licensees to take photographs or videos of me, and to make recordings of my voice. I give the UW permission to use these images, videos, and recordings, as well as my likeness, name, and voice, as follows:

The use may include reproduction, distribution, derivative works, display, and performance.
The use may be in composite or modified forms and in any media, now known or later developed, including without limitation newspapers, television, radio, the World Wide Web, and social media.
The use may be for any purpose throughout the world and in perpetuity, including, without limitation, education, trade, advertising, and promotion.

I further acknowledge that I will not be compensated for these uses,and that the UW exclusively owns all rights to the images, videos, and recordings, and to any derivative works created from them. I waive the right to inspect or approve of the uses of any printed or electronic copy. I hereby release the UW and its assigns and licensees from any claims that may arise from these uses, including without limitation claims of defamation or invasion of privacy, or of infringement of moral rights or rights of publicity or copyright.

This Release is binding on me, my heirs, assigns, and estate. The UW is not obligated to use any of the rights granted under this Release. This Release expresses the complete understanding of the parties.

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Add signature

Please provide any questions you'd like presenters to address during the session.

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Are you interested in participating in an ongoing regional group to support efforts to address maternal mortality in the State of Washington?

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Yes

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Thank you for your interest in the MMRP Report to the Legislature. We hope to meet you soon!

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