EMERGING LEADERS ALLIANCE

Dietary Restrictions or Allergies

Vegetarian Other (Indicate Below)

Deaf or Hearing Impaired Blind or Visually Impaired Wheelchair Bound

Other

Release/Permission: ELA reserves the right to make video/audio recordings and to take still photography during this workshop. My submission of this Registration form shall constitute my permission for ELA to use my voice, image, and likeness in any such photograph or video/audio recording, and to reproduce, distribute, display, sell, or otherwise use these photographs or recordings for any purpose, whether commercial or noncommercial in nature.

Please make payment below (US$1,350)

Payment Information

Pay by Credit Card

I would like to pay with my credit card.

Please provide your daytime phone number so we may call you for your credit card information.

I would like to pay via check. All payments are due three weeks prior to the conference.

(Check should be payable to AIST, in U.S. dollars and drawn from a U.S. bank) and mailed to: Emerging Leaders Alliance, c/o AIST, 186 Thorn Hill Rd., Warrendale, PA 15086.

Privacy Statement Agreement

I have read and agree to the AIST Antitrust Compliance, Anti-Harassment Policy and AIST Privacy Statement.

EMERGING LEADERS ALLIANCE

REGISTRATION FORM