H-Speaker Form

Workshop/Med Station

Speaker Form

Event Date: January 11, 2019
Location: Sonoma State University Student Center

Contact Info

* Indicates required field

Name: *

First

Last

Street Address: *

City, State, Zip: *

Phone: *

Fax: *

Email: *

(exactly as you would want it listed in the program)

Name: *

First

Last

Title: *

Affiliation: *

Presentation Title (title of workshop or med station): *

Short description of presentation topic: *

Bio to be used to introduce you at the conference: 100 words or less.

Short Bio *

I will submit a long bio for the syllabus. *

List any food allergies: *

Powerpoint: *

Speaker/Student Opportunity:
We may offer a few select students the opportunity to have lunch or shadow a speaker.

Speaker/Student Opportunity: Please check all that apply. *

Submit