66th annual addc convention - desk · 2017 addc board of directors desk and derrick members and...

66th Annual ADDC Convention

September 18-23, 2017

Holiday Inn Riverwalk

San Antonio, Texas

Hosted by Region IV

Desk and Derrick Clubs

REGISTRATION PACKET

President ..................................... Maggi Franks

President Elect ........................... Christina Forth

Vice President ................................. Terry Ligon

Secretary ...................................... Keith Atkins

Treasurer ................................. Tammy Watkins

Immediate Past President .................. Donna Siburt

Executive Assistant ........................ Linda Rodgers

Parliamentarian ....................... Sheryl Minear, RP

Region I Director . ............................ Bev Roberts

Region II Director ................................. Jan Bell

2017 ADDC Board of Directors

Desk and Derrick Members and Friends,

The Members of Region IV and the San Antonio Desk and

Derrick Club, invite you to attend the 66th Annual ADDC

Convention in San Antonio, Texas on September 18-23 2017.

Join us at the beautiful Holiday Inn Riverwalk, located in the heart of San Antonio. With the

beautiful Riverwalk adjacent to the hotel, you can walk to wonderful restaurants, enjoy some

wonderful Mexican food, ride the river barge to shop at the many stores, art galleries or just

enjoy the fantastic scenery.

The field trips, seminars and fun activities will keep you busy, learning about our industry,

visiting our beautiful city while having time to visit with old friends and making many new

ones along the way.

Field trips—visit an advanced technology manufacturing plant, take a trip to the Toyota

Plant and see first hand how these vehicles are manufactured, take a trip to the Hill Country

Wineries and shop in the historic Fredericksburg with a tour of the Nimitz War Museum or

how about visiting a refinery! These are just a few of the field trips planned.

Seminars—you can attend a seminar about “Leadership Training”, or learn about “The Evo-

lution of the Shale Revolution”; “Geology from Kitchen Tap to Gas Tank– Especially the

Gas Tank”; Cyber Security and Investigations to Catch Oil Thieves or plan on attending the

Certification Class covering Drilling. We have planned something for everyone!

Make your plans to come to San Antonio, deep in the Heart of Texas. We look forward to

seeing you all soon!

Association of Desk and Derrick Clubs

TENTATIVE AGENDA

Monday, September 18, 2017

8:00 am - 5:00 pm ADDC Board Meeting

5:00 pm - 8:00 pm Registration

Tuesday, September 19, 2017

8:00 am - 5:00 pm Board Field Trip

8:00 am - 10:00 am Registration


7:00 pm - 9:00 pm Regional Director Elect Training

Wednesday, September 20, 2017



6:30 am— 9:00 am Hospitality

3:00 pm - 8:00 pm Hospitality

7:30 am - 5:00 pm Wayne Manufacturing Plant Tour - Field Trip

8:00 am - 5:00 pm Hill Country Wine Tour and Fredericksburg, Texas

8:00 am - 4:00 pm Calumet Refinery & San Antonio Missions Tour

8:00 am - 4:00 pm Pioneer Energy Services Yard Tour

11:00 am - 4:00 pm Toyota Plant Tour-TMMTX

7:00 pm - 9:00 pm FREE Seminar-Lori Landry/ Sarah Hulin - “ What makes my Club Tick?”

Thursday, September 21, 2017

6:30 am - 9:00 am Hospitality

8:00 am - 5:00 pm Certification Class -Drilling

9:00 am - 11:00 am Seminar—Cyber Security, David Sohmer, Valero

9:00 am - 11:00 am Seminar - The Evolution of the Shale Revolution - Pete Bommer

1:00 pm - 3:00 pm Seminar - Geology from Kitchen to Gas Tank, especially the Gas Tank— John Long

Thursday, September 21, 2017 (continued)

1:00 pm - 3:00 pm Seminar - Leveraging Technology, Manpower & Investigative Skills to Catch Thieves, Mike Peters

2:00 pm. - 4:00 pm FREE Seminar - Leadership Training, Sheryl Minear

3:00 pm - 5:00 pm Team Building - Painting with A Twist

Friday, September 22, 2017



7:30 am Delegates Registration

8:00 am - 8:30 am Opening Business Session

8:30 am - 9:30 am Energy Symposium

9:30 am - 11:30 am Business Session

12:00 pm - 2:00 pm Industry Luncheon

2:15 pm - 5:00 pm Business Session

6:30 pm - 9:30 pm Movie Night

6:30 pm - 8:30 pm No Host Bar

Saturday, September 23, 2017


8:00 am Delegates Registration

8:30 am. - 11:30 am Business Session

12:00 pm - 2:00 pm Membership Recognition Luncheon

2:15 pm - 4:00 pm Business Session Resumes

4:00 pm - Board Meeting

6:00 pm - 7:00 pm No Host Reception

7:00 pm - 10:00 pm Banquet

Immediately after Banquet : 2017 & 2018 ADDC Presidents Reception

Sunday, September 24, 2017

7:00 am - 10: 00 am Hospitality

jonathan.slay

Text Box

FULL


Cost: $ 50.00/person

Advanced Technology Manufacturing Tour

Welcome to Wayne Fueling Systems

At our campus, you will get the opportunity to watch the production and assembly methods of a world class dispenser manufacturer. This fascinating process will expose you to the latest tech-nology in manufacturing.

You will see the step by step building process of “under-the-hood” technologies being built in-cluding:

Metering technology being assembled and tested

Flexible alternative fuel solutions being built

PCI and EMV encryption processes

QA processes and ISO Certification’s 1401, 9002 and 18,000

Digital and Industrial printing for dispenser graphics.

Tour Host – Dan Gleeson

10:00-10:30 Product and Company Overview

10:30-11:30 Factory Tour

11:30-12:00 Lab Tour

12:00-12:30 Help Desk / NOC Tour

12:30 -1:30 Lunch and Departure (Lunch provided by Wayne)

FIELD TRIPS

1. Wayne Manufacturing Plant tour 7:30 a.m.—5:00 p.m.

FIELD TRIPS

2. Hill Country Winery Tour & Fredericksburg, Texas 8:00 a.m.—5:00 p.m.

Cost: $50/person (Lunch on Your Own in Fredericksburg) Limited to 50 people

Take a leisurely bus ride to the beautiful Texas Hill Coun-try. There are over 30 Texas wineries in this area and we will be visiting several and taste some of the delicious wines, with plenty of time to select some to take home.

Because there are so many different cuisines in Fredericksburg

Lunch will be on your Own

After having some great wines, we will head over to have lunch in the historic town of Fredericksburg, Texas. The various foods leave you wanting to taste everything. From German to Mexican food, something for everyone. Lunch will be on your own.

Fredericksburg was founded in 1846 and named after Prince Frederick of Prussia. This beautiful little town Because there are so many different restaurants in Freder-icksburg, Old-time German residents often referred to Fredericksburg as Fritztown, a nickname that is still used in some businesses. The town is also notable as the home of Texas German, a dialect spoken by the first generations of German settlers who initially refused to learn English. Fredericksburg is the birthplace of Fleet Admiral Chester Nimitz. It is the sister city of Montabaur, Germany. On October 14, 1970, the Fredericksburg Historic District was added to the National Register of Historic Places in Texas.

Plenty of time to shop

‘till you

drop before heading

Back to

San Antonio!

Dedicated to all those who served in the Pacific War, the

Admiral Museum, George Bush Gallery of the Pacific War

and the Pacific Combat Zone are all part of this complex.


https://www.yelp.com/biz/six-shooter-cellars-fredericksburg?adjust_creative=bing&utm_campaign=yelp_feed&utm_medium=feed_v2&utm_source=bing

FIELD TRIPS

3. Calumet Refinery & San Antonio Missions Tour 8:00 a.m.—5:00 p.m.

Cost: $50/person NOTE: This Field Trip is limited to Twenty (20) people

Calumet Specialty Products partners, L.P. is a leading independent producer of high-quality, specialty hydrocarbon products. Product lines include both napthenic and paraffinic oils, aliphatic solvents, synthetic lubri-cants, asphalt, fuels, white mineral oils, waxes, petrolatums and hydrocarbon gels.

Calumet San Antonio Refining has crude oil throughput capacity of approximately 20,000 barrels per day. The refinery currently produces ultra-low sulfur diesel, jet fuel, LPG, Regular gasoline, JPTS, Atmospheric Tower Bottoms, specialty solvents, naptha and vacuum gas oil. There is approximately 200,000 barrels of storage capac-ity and approximately 200,000 barrels of crude oil storage at a crude oil terminal.

Leaving the refinery, you will go to The Pearl for lunch. What is Pearl? Pearl is a neighborhood and like all great neighborhoods it has a rich history that is added to and upheld by the many people who have ties to the place, the buildings, the river, the brewery since it was founded in 1881. Commitment to food is in every corner of

Pearl. The Pearl is the home of the third campus (along with New York and Califor-nia) of the U.S Culinary Institute.

(Lunch at The Pearl—on your own)

After lunch you will enjoy the historical San Antonio Missions

Enjoy a tour of the four historical San Antonio Missions. Visit the Mission Espada, Mission San Juan, Mission San Jose and Mission Conception. The chain of missions established along the San Antonio River in the 1700s is a re-minder of one of Spain’s most successful attempts to extend its dominion northward from New Spain (present-day Mexico). Collectively they form the largest concentra-tion of Catholic missions in North America. Tales of riches spurred the early Spanish explorers northward across the Rio Grande. By the 1600s Spaniards penetrated areas to the east, encountering the Tejas Indians for whom Texas is named. As dreams of wealth faded, the Spanish concentrated more fully on spreading the Catholic faith—the basis of Spanish colonial society—among the frontier Indians. Financed by the Crown, Franciscan missions served both Church and State. As an arm of the church, the mission was the vanguard for converting the Indians spiritually. As an agent of the state, the mission helped push the empire northward. Missions also offered Indi-ans sanctuary from their enemies


jonathan.slay

Text Box

The Calumet field trip is FULL, as of 5/30/2017.


Cost: $50.00/person

“ Overview of Cased Hole Logging Tools and Operations”

We will take a short bus ride to Seguin, Texas to visit the Pioneer Energy Services Training Center Yard. Start the tour with a power point presentation about cased hole logging tools and services. Followed by a demonstration of the operations which will be run in Pioneer’s test well at this location. Testing the well will result in a log display, similar to actual field operations. We will end the day after lunch, which will be provided by Pioneer and we will then begin our trip back San Antonio.

Cost: $50.00/person

Take a plant tour for the ultimate TMMTX experience! You will see what goes into the manufacturing of the Toyota Tundra and Tacoma, as they roll off the line each day. Our friendly tour guides will take you through 2.2 million square feet of the facility.

Start the journey in the Body Weld Shop, where a team of computer-controlled robots use state-of-the-art technology weld stamp steel pieces together. Next into the Plastics Shop, where critical components including the vehicle bumpers and instrument panels are made. On to see overhead conveyors transport the trucks from Paint to Assembly where the trucks begin to take shape. Throughout the tour your guide will point out the foundations of the world-renowned Toyota Productions System, as well as give you insight to the line side processes of the TMMTX Team members. Across America, Toyota is Helping Those in Need As a good corporate citizen, Toyota contributes to econom-ic and social development in local communities. Giving back to the communities where team members live and work is a priority for Toyota. We believe in helping people improve the quality of life in their communities through educa-tion and family literacy programs. We also partner with leading organizations that edu-cate children and their families about creating a cleaner, greener and healthier world. Important Info: No carry-on is permitted in the Visitor Center including purses, back-packs, briefcase or bags of any kind. Cameras are allowed into the Visitor Center, but must be checked in at the registration desk before the plant tour. Only long pants (no shorts/skirts); shirts must have sleeves (short sleeve okay), midriffs must be covered; closed toe shoes are a must. Safety glasses/hard hats will be supplied.

FIELD TRIPS

4. Pioneer Energy Services Yard Tour 8:00 a.m.—4:00

5. Toyota Plant Tour - TMMTX 11:00 a.m.—4:00 p.m.


Cost: $75.00 for members - $125.00 for non-members

Steve L. Bruington, P.E., is the President of Bruington

Engineering, LLC, which provides in-house engineer-

ing and well site consulting services, will be the in-

structor for the certification class. The services pro-

vided by Bruington include onsite supervision of drill-

ing, completion and workover operations; snubbing

operations; pipeline testing, inspection of outside oper-

ated properties and supervision of gaugers.

Steve is also a partner in Bruington Operating Compa-

ny LLC, which is actively engaged in contract operating of oil and gas wells. He was the

project manager for drilling of under-balanced horizontal Buda wells, utilizing crude oil and

nitrogen in an H2S environment.

Steve received a Bachelor of Science Degree in Petroleum Engineering from Texas A&M

University in 1976.

Joe Sample

The American Oil & Gas Reporter

CERTIFICATION CLASS

History of Drilling

Planning a well

Rig Equipment

Drilling contracts

Bits

Mud Selection

Well Head

Cementing

Logging

Moving in/rigging up

Wellbore schematic

Class Overview

Smith/SLB

www.umb.co.id

Certification Class - Drilling 8:00 am - 5:00 pm


Cost: FREE

WHAT MAKES MY CLUB TICK

So what makes my Club tick? Is it the networking? Is it the comradery? Is it the monthly

speakers and topics? Does your Club’s clock “tick” in the right direction? Does it Spring

Forward and keep good time or has it Fallen Back, lost time and need a battery change?

Lori Landry and Sarah Hulin, members of the Desk and Derrick Club of Lafayette will share

with you what makes their own Club “Tick” and offer tips and ideas to get your own Club back on track and “Keeping Good Time”. __________________________________________________________________

Lori Landry has worked in the Oil and Gas Industry for over 36 years. She is currently the Land/Regulatory Manager for White Knight Produc-tion, LLC where she is responsible for all land related disciplines as well as accounting functions such as revenue, joint interest billing and ac-counts payable. She also coordinates and submits regulatory reports, maintains operations histories and supports acquisition and divestment evaluations and processes.

Lori was most recently the Land/Accounting Manager for Bean Resources, Inc. where she worked for 18 years handling many of the same responsibilities as with White Knight with a primary focus on operations in Mississippi. Prior to working at Bean Resources, Inc., Lori was the Land/Accounting Manager for Source Petroleum, Inc. for 16 years.

A native of Lafayette, Louisiana, Lori is an active member of the Association of Desk and Derrick Clubs where she served as the International President in 2015. She is the Managing Member of Big Shot Promotions, LLC, a local Advertising and Promotional company and is a member of several Mardi Gras Krewes in Lafayette.

Sarah Hulin has worked in the oil and gas industry for over 15 years.

She is currently the Office Manager of T. Baker Smith, LLC, an engineer-

ing, environmental and survey consulting firm. After graduating college,

with a math degree for high school education. Sarah taught math for a

year. At the end of that year, she realized her heart was not in it. Sarah

found her passion for business in the oil and gas industry.

A member of Desk and Derrick for almost 10 years, Sarah has served on

various committees, has been a Board member for five years and began her term as President

of the Lafayette Club in January, 2017. “It is my honor to represent this phenomenal club.”

SEMINARS

1. What Makes My Club Tick 7:00 p.m.—9:00 p.m.


Cost: $30.00 per person

Everyone recognizes the vital role that technology plays in our daily lives. Whether we are at work doing our jobs, keeping in contact with family or friends, managing personal finances or performing research, securing your personal, and your company’s, online information is be-coming more and more critical. Security is a shared responsibility, and each of us plays an important role in it. Over the course of the next hour, we will talk about various Cyber Security topics such as: password complexity, social engineering, SPAM, how to recognize malicious e-mail, securing your home com-puter and an overview of recent high profile security incidents . Making cyber security a priority is critical as we rely more and more on digital networks to do business and manage our family affairs. By taking just a few simple steps toward protect-ing yourself online, you and your family members will stay protected.

David M. Sohmer, CISSP, Is the Senior Manager—Information Security for Valero Energy Corporation. He previously was Security Director at General Dynamics Armament and Technical Products in Charlotte, NC. He oversaw all security operations, both physical and IT. Served as General Dynamics Information Systems Security Officer. He has a Masters Degree in Operations Management for the University of Arkansas.


The Evolution of the Shale Revolution is a look at the history of unconventional development and the latest in fracturing techniques.

The revolution in unconventional shale development has been

exactly that—revolutionary. Driven from its infancy by advances in technology, shale drilling has almost single-handedly reversed the chronic decline in American oil production and freed us from the specter of total reliance on foreign sources. While progress in drilling and production techniques have been remarkable, the real cutting edge in this revolution continues to be in completion prac tices, particularly hydraulic fracturing.

Peter A. Bommer is the Vice President of Engineering with Abraxas Petroleum Corporation in San Antonio, Texas. Peter was born into an oilfield family; Peter and his brother Paul, ran Bommer Engineering for many years. In 2007, he joined Abraxas Petroleum Corporation.

In his capacity, Peter is in charge of all corporate engineering, as well as fracture stimulation design in the company’s Bakken, Eagle Ford, and Wolfcamp unconventional plays.

SEMINARS

2. Cyber Security 9:00 am - 11:00

3. The Evolution of the Shale Revolution 9:00 am - 11:00 am



Everyday life items such as water and components of food, homes and cars are made of natural resources found and studied by geologists. Geologists predict groundwater availability, study salt gypsum and coal mines and find future oil fields. Many scientists warn that in-creased oil and gas use will cause a global warming, but paleoclimate studies by geologists and a theory devised by astrophysicists offer al-ternative explanations. At this time it appears that the oil and gas in-dustry will be supplying adequate and justified energy for many dec-ades until a yet to be discovered source of abundant and inexpensive energy is established.

John Long studied geology at the University of Missouri and the University of Texas. He has worked for Texaco, Inc, Gulf Oil Company, Placid Oil Company and Osborn Heirs Company. He is Currently an independent geologist generating prospects and Consulting in South Texas.


Did you know that it is estimated that 1% to 3% of all oil and condensate produced in Texas is stolen? How do you steal oil? What do you do with it one you have stolen it? More importantly how do you catch those steal-ing the oil? These are questions that will be explored in this presentation, along with real case studies that show how the proper use of Technology, Manpower and Investigative skills led to the capture and arrest of a criminal organization.

Mike Peters is the Global Security Manager for Lewis Energy Group in San Antonio. He was a police officer with the San Antonio Police Department for 33 years. In 1994 Mike was promoted to Sergeant and formed and took command of the SAPD Electronics Surveillance Unit.

In 2008 he was the acting Security Manager for the City of San Antonio and also the New Technologies Manager for the Police Department. Mike has worked for Lewis Energy since 2011, and is currently the Head of the Security Department.

SEMINARS

4. Geology from Kitchen to Gas Tank—Especially the Gas Tank

1:00 pm - 3:00 pm

5. Leveraging Technology, Manpower and Investigations

to Catch Oil Thieves 1:00 pm - 3:00


Cost: FREE

Need help developing leadership skills and taking on the role of a leader? Can’t find the time to step into a leadership role? The ADDC Leadership Resource Committee is pleased to pre-

sent a Leadership Seminar that will focus on developing leadership skills and time management. The seminar will be held on Thursday, September 21 and there will be no charge.

Sheryl Minear, Past ADDC President, will be the speaker. Sheryl has been a member of ADDC since 1983. She served as Region V Direc-tor in 1997. In 2005 Sheryl served on the ADDC Board as Treasurer, Vice President in 2006, President-Elect in 2007, President in 2008 and Immediate Past President in 2009. Sheryl also served as the ADDC Parliamentarian for several years.

Sheryl served on several ADDC committees throughout her years as a member, the most notably being the Certification Program Committee.

Sheryl was named the United States Energy Person of the Year by Nickles Energy in 1999.

Cost: $40.00 per person On site at Hotel

Let your creative juices flow - become the artist that you always wanted to be and enjoy the company of old and new friends. Create a wonderful picture filled with memories while you are in San Antonio.

SEMINARS

6. Leadership Training 2:00 pm - 4:00 pm

7. Team Building - Painting with a Twist 3:00 pm - 5:00 pm

Come on down and take in a Movie -

“Deep Horizon”

Enjoy the casual evening, dining on your favorite Movie Night Food and watching the great movie “Deep Horizon”. This is a 2016 American biopic disaster film, directed by Peter Berg, written by Matthew Sand and Matthew Michael Carnahan.

Staring an ensemble cast including Mark Wahlberg, Kurt Russell, John Malkovich, Gina Rodriguez, Dylan O’Brien and Kate Hudson. It is based on the 2010 Deepwater Horizon explosion and oil spill in the Gulf of Mexico.

Time to sit back, relax with friends and have that special time to catch up with each other. Come in comfy clothes, sit around, watch the movie and just plain old chill and “hang out”.

Friday Night Networking

HOTEL INFORMATION

Holiday Inn Riverwalk - San Antonio, Texas

217 North St. Mary’s Street, San Antonio Texas 78205

If making reservations on line - Use the Booking Code: ADDC 2017 or call the Hotel di-

rect at 210/224-2500 and ask for the Association of Desk & Derrick Clubs Group

Room Rates: $149 Single / $159 Double (Includes full breakfast buffet voucher)

Deadline for Reservations—August 28, 2017 Reservations received after that date will be

provided on a space available basis at the hotel’s current rate.

REGISTRATION FORM - MEMBER

Please use separate form for each registrant

Please Print:

First Name: __________________________ Club: _____________________________

Last Name: __________________________ Delegate: ________ Alternate: ________

Company: __________________________ This is my first ADDC Convention _____

Office Phone: ________________________ Special Dietary Restrictions___________

Home Phone: ________________________ _________________________________

E-mail: _____________________________ Past ADDC President __________ (year)

Current ADDC Position:________________ Member # __________ Region: _______

REGISTRATION DEADLINES: Members/

Guest: Early Registration Postmarked prior to

Aug. 1, 2017

Late Registrations: Postmarked after Aug. 1, 2017

REFUND POLICY: FULL Refund (Postmarked)

August 26, 2017. Refunds may be made if funds

are available. NO REFUND after September 9,

2017.

RETURNED CHECK POLICY - $50.00

Amount

Registration Fee: $225.00 Includes: All Business Sessions, Friday Industry Luncheon, Friday Night Ice Breaker, Saturday Recognition Luncheon, and Saturday Banquet

$

Late Registration Fee: $250.00 (Registration after –8/1/2017 - 8/26/2017

$

Please enter Field Trip, Seminar or event and cost below:

Certification Class - “Drilling” $

Field Trip No. __________________

Seminar No.____________________

Seminar No. ____________________

Seminar No. ____________________

Seminar No. ____________________

Seminar No. ____________________

TOTAL

$

Credit Card Charge: _____MasterCard _____VISA ____Discover Card # _____________________________ Exp. Date: ___________ Signature: __________________________ Date: ____________ All credit card registrations process in U.S. funds. Please note that we do not accept credit card information via e-mail. Credit card registrations must be sent via mail, or telephone

Checks Payable to: ADDC Convention Fund

U.S. and Canadian registrants pay by check

in U.S. Funds.

Mail to: P. O. Box 843, Bethany, OK 73008

ADO Phone # 405-543-3464

Contact:__________________________

E-Mail: __________________________

Telephone: ________________________

Please fill out emergency information form

and attach to registration before sending in.

REGISTRATION FORM—NON-MEMBER/GUEST

Please use separate form for each registrant

Please Print:

First Name: __________________________ Home Phone: _____________________

Last Name: __________________________ E-mail: __________________________

Company: __________________________ Guest of: _________________________

Office Phone: ________________________ Special Dietary Restrictions___________

Home Phone: ________________________ _________________________________

REGISTRATION DEADLINES: Members/

Guests: Early Registration Postmarked prior to

August 1, 2017

Late registration: Postmarked after Aug. 1, 2017

REFUND POLICY: FULL Refund (Postmarked)

August 26, 2017. Refunds may be made if funds

are available. NO REFUND after September 9,

2017.

RETURNED CHECK POLICY - $50.00

Amount

Please enter Field Trip, Seminar or event and cost below:

Friday Industry Luncheon $ 50.00

Friday Night Ice Breaker $ 50.00

Saturday Recognition Luncheon $ 50.00

Saturday Banquet $ 80.00

Certification Class - “Drilling” $

Field Trip No. __________________

Seminar No.____________________

Seminar No. ____________________

Seminar No. ____________________

Seminar No. ____________________

Seminar No. ____________________

TOTAL

$

Credit Card Charge: _____MasterCard _____VISA ____Discover Card # _____________________________ Exp. Date: ___________________ Signature: __________________________ Date: ____________ All credit card registrations process in U.S. funds. Please note that we do not accept credit card information via e-mail. Credit card registrations must be sent via mail, or telephone.

Checks payable to: ADDC Convention Fund

U.S. and Canadian registrants pay by Check in

U.S. Funds

Mail to: P. O. Box 843, Bethany, OK 73008

ADO Phone # 405-543– 3464

__________________________________

Contact:___________________________

E-Mail:___________________________

Telephone: ________________________

Please fill out emergency information form and

attach to registration form before sending in.

Medical Release Form

This form is to be completed by each person (member or guest) attending any ADDC Convention activities. Signed release forms must be received before departure on any field trip or any special event. PLEASE RETURN THE SIGNED RELEASE FORM WITH EACH REGISTRATION FORM (This form may be copied for additional reservations. The information provided here is regarded as confidential.)

Club Name: ______________________ (For members only) Last Name: ______________________ First Name: ______________________ IN CASE OF EMERGENCY, PLEASE NOTIFY: Name: _________________________ Relationship: _____________________ Contact #: ______________________ Email Address: ___________________ I understand that my participation in the field trips or special events is at my own risk and responsibility. The Association of Desk and Derrick Clubs assume no liability. Signature: _________________________ Date: _________________________

MEDICAL RELEASE FORM

(Must be completed by each Member or Guest)

66th annual addc convention - desk · 2017 addc board of directors desk and derrick members and...

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