CHCA Speaker Information Request Form

Name: Colorado Health Care Association
Address: 4100 E. Mississippi Ave. Suite 925, Glendale, CO, 80246
Telephone: 303-861-8228

Speaker Name*
Speaker Title*
What are the speaker's preferred pronouns?*
Speaker Company*
Best Contact Email for Speaker*
Best Phone Number for Speaker (please include extension if applicable)*
Speaker Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

For the confirmation letter
Webinar Title*
Webinar Date*
Webinar Time*

Please note all webinars will be held in MST
Speaker Timezone*
Webinar Duration*

How long will your presentation be?
Target Audience*
Synopsis of Webinar*
Please include any summaries/bullet points you would like included on the brochure
Program Material
Max. file size: 21 MB.
Please upload any program material that will be used during the presentation.
Webinar Practice Demonstration*

CHCA requires that all speakers presenting a webinar do a 15 minute run through regarding how our webinars operate to make sure our speakers feel comfortable with the software and have a stable internet connection. Please list 3 available dates and times between now and the date of the webinar for the run through
During the program, would you like the questions submitted through the Q/A function read out as they are received, or saved for the end?*
Would you like to introduce yourself before the program or would you like CHCA to introduce you?*
Please submit a biography for the speaker(s)*
Please Provide the Name & Contact Information of Any Additional Presenters

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