Caucus Registration This is an Invitation Only Meeting. Due to health and safety concerns related to the COVID-19 pandemic all attendees will be required at on-site registration to provide proof of vaccination, or a negative COVID-19 test result within 3 days of the start of the meeting to attend. Masks are required at the 2021 Movement is Life Caucus.Name* First Middle Last Credentials*Preferred name for badgei.e. Mike instead of MichaelJob Title*Business Name*Business Address* Street Address Address Line 2 City State ZIP AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Business Phone*Business Email* This email will only be used for correspondence for this meeting and Movement Is Life updates.What is your Profession?*selectAttending FacultyResidentMedical StudentOther StudentNurse/Physician AssistantOtherType your profession if not in the list above.*Are you a LICENSED healthcare professional?*selectyesno Mode of TransportationselectAirplaneAutomobileBusTrainWhat are your planned accommodations for the Caucus?*selectHost HotelAir BnBFamily/FriendsAlternate HotelHomeOtherPlease list any dietary restrictions, requirements or food allergiesYou are attending this meeting at your own discretion and will pay for all expenses related to attendance including, but not limited to, travel and accommodations. If this meeting cancels for any reason, you understand that your expenses will not be covered or reimbursed and remain your responsibility. Please check this box to acknowledge that you understand these terms.*I agreeI agree that my email address can be included in Movement Is Life database and distributed to Caucus participants.*yesnoNext Step: Please click Submit below in order to complete the registration process. To register for our programs, we will ask you to provide your name, postal address, email address, telephone number and possibly other personal information related to this particular program. The information we collect will be used to confirm your registration or enrollment. In addition, we may use that information to contact you by email or regular mail to invite you to other events or to provide you with information about Zimmer Biomet products and/or services that we believe may be of interest to you. Your information may be shared with third party business partners who are assisting Zimmer Biomet, as well as other Zimmer Biomet affiliates, including those in other countries. Some of these countries may not provide the same level of data protection as the laws of your country. However, we take steps to ensure that your information is reasonably and appropriately safeguarded from unauthorized access, regardless of the country. In addition we never sell or transfer your personal information to any third party for their own use. You have the right to cancel, amend or correct your information, and we encourage you to contact us in the event that your information changes so that we can keep it accurate. In addition, you always have the right to withdraw your consent. There is an unsubscribe link provided in each email message by or on behalf of Zimmer Biomet. You can also use our Contact Us link at www.zimmerbiomet.com or call us at 877-946-2761. Please review our website privacy policy for additional information about our data privacy practices. PLEASE NOTE: You have selected that you ARE a healthcare professional. If you are NOT a healthcare professional, please select Previous and return to the previous page to correct your response. It is the last question on the previous page. Are you licensed in VT?*yesnoVermont law prohibits Zimmer Biomet from paying for meals as part of your attendance at this meeting. Therefore, if you choose to participate in meal functions you will be asked to provide payment to cover the cost of meal functions. A member from the meeting planning team will contact you regarding your meal payment options.Mode of TransportationselectAirplaneAutomobileBusTrainWhat are your planned accommodations for the Caucus?*selectHost HotelAir BnBFamily/FriendsAlternate HotelHomeOther Zimmer Biomet is required to report payments and transfers of value to or on behalf of licensed physicians and teaching hospitals per state and federal transparency reporting laws. "Transfer of value" include but are not limited to: meals, snacks, travel and any reimbursed expenses.Please provide your license number and state of issue for ALL states in which you are licensed.*Please provide your National Provider Identifier (NPI) number below if applicable.Type of healthcare professional (i.e. Rehab Nurse, Orthopaedic Surgeon, Primary Care Physician)*What is your area of specialty? If you do not have a specialty please enter N/A.*Please list any dietary restrictions, requirements or food allergiesYou are attending this meeting at your own discretion and will pay for all expenses related to attendance including, but not limited to, travel and accommodations. If this meeting cancels for any reason, you understand that your expenses will not be covered or reimbursed and remain your responsibility. Please check this box to acknowledge that you understand these terms.*I agreeI agree that my email address can be included in Movement Is Life database and distributed to Caucus participants.*yesnoNext Step: Please click Submit below in order to complete the registration process. To register for our programs, we will ask you to provide your name, postal address, email address, telephone number and possibly other personal information related to this particular program. The information we collect will be used to confirm your registration or enrollment. In addition, we may use that information to contact you by email or regular mail to invite you to other events or to provide you with information about Zimmer Biomet products and/or services that we believe may be of interest to you. Your information may be shared with third party business partners who are assisting Zimmer Biomet, as well as other Zimmer Biomet affiliates, including those in other countries. Some of these countries may not provide the same level of data protection as the laws of your country. However, we take steps to ensure that your information is reasonably and appropriately safeguarded from unauthorized access, regardless of the country. In addition we never sell or transfer your personal information to any third party for their own use. You have the right to cancel, amend or correct your information, and we encourage you to contact us in the event that your information changes so that we can keep it accurate. In addition, you always have the right to withdraw your consent. There is an unsubscribe link provided in each email message by or on behalf of Zimmer Biomet. You can also use our Contact Us link at www.zimmerbiomet.com or call us at 877-946-2761. Please review our website privacy policy for additional information about our data privacy practices.
