Request to Speaker Form

First name

Last name

Phone

What Company are you with?

Provide your professional title and credentials, if applicable.

Have you spoken before a large crowd before?

What is your proposed Topic?

Please write a short description of your proposed presentation.

It's time to give us your bio (150 words or less). This can include academic, professional, or real-world experience.

What makes you a good choice to present on this topic? What expertise or experience do you have relative to this topic? Do you have any pertinent company affiliations?

In 1-2 sentences, what is your message to travelers? (sell yourself & your presentation). Why should a healthcare traveler attend your session?

Please drop a headshot photo here for our website and program.

Last thing if you have any social media handles or URLs you would like included in our online promotions, please include them here.