December 2- 4, 2019 CreativeOne11460 Tomahawk Creek ParkwayLeawood, Kansas 66211United States [email protected]1-800-992-2642 Event ID 2605 Medicare 101 Date(s)12/02-12/04 Step 1 of 3 33% Email:* Name: First Last Name As It Would Appear On Badge: Company Name: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Office Phone:*Cell Phone:* Additional Information:Emergency Contact Name:* First Last Emergency Phone:*What is your T-Shirt size?MLXLXXLDo you have any medically necessary food allergies? Travel & Lodging Details:Travel arrangements will be made through our designated travel partner, Direct Travel. Once you submit your registration form, you will be contacted via email with a flight itinerary containing the best available schedule and fare from the closest major airport. Please confirm your schedule within 24 hours of having been contacted by Direct Travel by either responding to the email or placing a call to them. Your response to Direct Travel within 24 hours of receipt will hold your seats on the proposed itinerary, but does not guarantee the rate until time of booking.Will you be driving or flying?*DrivingFlyingName as it appears on Driver's License:* First Middle Last Date of Birth:* MM slash DD slash YYYY (Required for air reservations)Gender:*MaleFemalePlease enter your desired departure city OR the airport code:* TSA Pre-check # (if applicable): Seat Preference:*AisleCenterWindowLodging - Do you need a hotel?* Yes, please reserve my rooms for program dates 12/02 - 12/04 Yes,please reserve my rooms outside program dates. No, I do not need a hotel. Attendees will stay at the Sheraton Overland Park Hotel in Overland Park, Kansas. When you register for the event, a room reservation will be made in your name at the Sheraton Overland Park for December 2 - 4, 2019 (unless you indicate you will not need a room on your registration). Please DO NOT contact the hotel for reservations as they will be made by CreativeOne. For more information on this hotel, go to their website.What is your arrival date?* MM slash DD slash YYYY What is your departure date?* MM slash DD slash YYYY Please share any special travel needs: Terms and Conditions* Do you agree to the terms and conditions? ASSUMPTION OF RISK With your submission of this registration for your CreativeOne Agent event, you will be accepting the risks involved with this event. These risks may include, but are not limited to: acts of God; terrorism; use of roads, vehicles, accident or illness, or consumption of alcohol by you or others. You agree to be responsible for your own welfare, and accept any and all risks of unanticipated events, illness, injury or death. We expect all guests to exemplify our high ethics, standards and professional code of conduct with which our company prides itself. Any issues brought to our attention that are not reflective of this will be handled on a case-by-case basis and when applicable, at the expense of the offender. RELEASE For being permitted to participate in the Program, you hereby Release and discharge CreativeOne, Conference Event Management, Direct Travel, their employees, agents, and others assisting or otherwise affiliated with the program from any claims, damages, and liability of any kind associated with your participation in the program except liability for those willful or malicious acts by the sponsors. The sponsors shall have no responsibility for any injuries, losses, or damages of any kind resulting from your participation in the program and the sponsors shall be held harmless against any claims of liability arising directly or indirectly from your participation in the program or any injury, accident, illness, or damages (including death). By Registering you are authorizing CreativeOne and its designees the right to use your name, likeness, image, voice, appearance, and performance as embodied in the Product whether recorded on or transferred to videotape, film, slides, photographs, audio tapes, or other media, now known or later developed. By submitting your registration, we understand that you have read and fully understand this agreement and its ramifications. You understand this is an enforceable contract. Your reply is at your own free will. If you have any questions about this agreement or the program, you have asked them and you have been provided with information which was to your satisfaction.