Speaker Proposal Form

KRCS Speaker Submission Form

Name

First Name

Last Name

Credentials

Place of Employment

Job Title

Phone

(###)

###

####

Lecture Title

List 2 measurable learner objectives for your talk

Please provide a paragraph summary of your talk to be placed in our program

Please describe your expertise on this topic

Previous speaking experience

Please provide a paragraph bio to be used as your profile in our program

Do you have a sponsor?

If yes whom and will they cover all expenses: Food, travel, honorarium?

Would you be willing to do webinar or in person

Are you willing to pay for a protion of your travel if you do not have a sponsor?