2022 Speaker Interest Form

First Name

Last Name

Organization

E-mail

Mobile

Speaker Bio

Topic Areas

In Just a Few Sentences, What Makes your Presentation Style Unique and Engaging

Speaker Fee Range

Link to Video of Previous Presentation(s) if Applicable

Please List the Child Health Areas of your Presentation(s): ie. Immunizations, Obesity, Lead, Infant Mortality, etc.

What is your Preferred Method of Delivery?

In-person

Virtual

OtherOther

Please Select All Words that Describe Your Content

Practice Issues

Diversity/Inclusion

Adolescent Health

Infant/Newborn

School Age

Payment/Reimbursement

Advocacy

Technology

OtherOther

What is your Target Audience?

Pediatricians

Nurses/Mid-Level Providers

ResidentsResidents

Medical Students

Allied Health

OtherOther

Sample Slidedeck from Previous Presentation

Drop a file here or click to upload Choose File

Maximum file size: 268.44MB

How Often Do you Present at Conferences?

Annually

1-2 Times Per Year

3 or More Times Per Year

Monthly

Weekly

Submit

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