CHCA In Person Speaker Information Form

Speaker Name(Required)

Speaker Company(Required)

What are the speaker's preferred pronouns?(Required)

Speaker Title(Required)

Speaker Company(Required)

Company Logo(Required)

Best Contact Email for Speaker(Required)

Best Phone Number for Speaker (please include extension if applicable )(Required)

Speaker Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

For the confirmation letter

Speaker Time Zone(Required)

Program Title(Required)

Length of Training(Required)

How long is the presentation anticipated to be.

Program Material

Max. file size: 21 MB.

Please upload any program material that will be used during the presentation.

Program Target Audience(Required)

Please list all discipline(s) this presentation applies to.

Program Synopsis(Required)

Please add a synopsis of your presentation in 250 words or less.

Please submit a biography for the speaker(s)(Required)

Please provide the name & contact information of any additional presenters

Would you like to introduce yourself before the program or would you like CHCA to introduce you?(Required)

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