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

CHCA Webinar Speaker Information Form

CHCA Webinar Speaker Information Form

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