2023 She Elevates Academy Participation Form Name* First Last 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 Email* Phone*How are you involved in the Academy? (Check all that apply.)* Instructor SHERO/Speaker Moderator in Groups Mistress of Ceremonies Time Keeper Team Member Technical/Admin SHERO only enter Brief Bio (150 words or less)Will you be using PowerPoint?* Yes No Yes or No, if yes email slides to assist@sheelevates.orgWill you be playing music?* Yes No If yes give the name of the song. If you plan to use music, please enter the name of the song and the artist. Please upload your headshot OR email it to jeanette@gossamer.marketing Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB. VIDEO RECORDING AND PHOTO RELEASE AND WAIVER I do hereby give She Elevates Inc. and DeLores Pressley Worldwide, its assigns, licensees, and legal representatives the right to use my name (or any fictional name), picture, portrait or photograph in all forms and media and in all manner, for advertising, trade or in any other lawful purpose for the benefit of the She Elevates, Inc. I hereby waive any right to inspect or approve the finished product, including but not limited to, written copy, video, and/or an image in print or on a website, specifically Zoom, that may be created in connection therewith. I am eighteen (18) years of age or older and understand that She Elevates Inc./DeLores Pressley Worldwide cannot control the unauthorized use by persons other than She Elevates, Inc or DeLores Pressley Worldwide, of my name or image once such name or image is published. Any claim I may have concerning unauthorized publication of my name and image must be pursued by me against the unauthorized user. She Elevates, Inc. and DeLores Pressley Worldwide disclaims any responsibility for such unauthorized use of my published name or image. I have read and understand the provisions contained above and agree to be bound by them. I voluntarily and give my consent without compensation and agree to this Release and Waiver.Signed By* By typing my name above I am authorizing this entry to be used as my electronic signature.Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
