Form Builder

E-Mail

Salutation

First Name

As you would like it to appear in programming and on your badge, including capitalization, periods, and spaces.

Last Name

Credentials

eg. MD, CNS, RN, PhD

Website URL

Facebook Profile or Page URL

Full URL, starting with https://facebook.com/

Twitter Username

Just the username, no @

Instagram Username

Just the username, no @

YouTube URL

If you have a YouTube channel, include the full URL here.

Speaker Bio

Podcast

If you host a podcast, please list the title here (as it appears in Apple Podcasts).

Phone

Address

Address Line 2

City

State or Territory

Postcode / Zip

Country Code

three letter country abbreviation

Speaker Preference

Let us know which speaking experiences you are interested in.

Speaker
Panelist

Presentation Topic 1

Please provide three possible topics for your presentation. When we approve your application, we will select one of them to display on the website along with your bio and portrait. We will let you know which topic we have approved.

Presentation Topic 2

Presentation Topic 3

Speaker Portrait

Will be cropped automatically. Please use a portrait (no full-body), fully clothed (e.g., no body-building competition day photos, no swimsuits, or partially nude images). No illustrations/Bitmoji or IG/Snapchat filters.

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