First Name * Last Name * Agency Title Phone * Email * Dietary Restrictions Mobility Restrictions Photo Release * I hereby authorize High Country Area Agency on Aging (HCAAA) to publish the photographs taken of me, and my name, for use in the HCAAA’s printed publications and website. I acknowledge that since my participation in publications and websites produced by HCAAA is voluntary, I will receive no financial compensation. I further agree that my participation in any publication and website produced by HCAAA confers upon me no rights of ownership whatsoever. I release HCAAA, its contractors and its employees from liability for any claims by me or any third party in connection with my participation. Select Payment Method * Check ($60 early registration through Sunday, September 9) Credit card ($62.50 early registration through Sunday, September 9) Check ($70 after Sunday, September 9) Credit card ($73 after Sunday, September 9) Submit
