Submitted by

 

Contact Phone Number or Email

 

 

Provider Speaker Name

 

 

Co-presenter (If applicable)

Title

 

Title

Company

 

Company

Industry Experience (years)

Industry Experience (years)

Email

 

Email

Phone

Phone

AzHAM Member (yes or no)

 

AzHAM Member (yes or no)

 

 

List events and dates where speakers presented recently (If applicable)

 

 

 

 

 

 

Session Title

 

 

Learning Objectives and Session Outline (Attach additional pages if necessary)

 

 

 

 

 

 

 

Describe methods of Teaching (Lecture, Round Table discussion, Panel, AV Equipment Needs)

 

 

 

 

 

 

 

 

 

 

 

Please complete the following statement by filling out at least three of the boxes below.  “After this session, you will be able to:”

Number 1:

Number 2:

Number 3:

  By checking this box, the individual submitting this proposal agrees and/or acknowledges that:

All speakers listed in this proposal have already agreed to present at this event.

1. Each speaker will receive one (1) complimentary registration to the annual conference.

2. If one or more speakers cancel their appearance at the event, every reasonable effort will be made by the individual submitting this proposal to replace that person with a speaker from a similar company with a similar or higher-level title and with similar or better subject matter expertise.

3. Speakers will be required to furnish the event organizer with a copy of their presentation, handout materials and any other media to be used during the session within the timeframe outlined in this document.

 

 

Speaker Proposal Form

Arizona Association of Healthcare Access Management