MAND 2022 Annual Conference Speaker Application Form

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The MAND annual spring conference is set for April 8, 2021 in Freeport, Maine. We will continue to monitor the pandemic conditions and adjust as necessary for public health considerations.

Please submit the following information for consideration as a speaker for this conference. The conference planning committee will be back in touch with you after your submission. For questions, email eatrightmaine@gmail.com

Email *

Presenter Name *

Presenter Credentials

Presenter Title and Organization

Presenter Phone *

Please note your professional memberships

Co-Presenter Name (if applicable)

Co-Presenter Credentials

Co-Presenter Title and Organization

Co-Presenter Email Address

Please note professional memberships of Co-Presenter

Other professional memberships of Co-Presenter

Please check all that apply: *

I am willing to present virtually

I am willing to travel if circumstances allow

Required

Session title *

CEU level (1, 2, or 3)

Session description or presentation summary (less than 100 words) *

Objective 1 *

Objective 2 *

Objective 3

Performance Indicators (https://bit.ly/CDR_PI)

Include (or provide separately) a speaker bio in 200 words or less. *

Indicate if you have possible or confirmed sources of funding or sponsorship for your session *

I have funding/sponsorship

I may have funding/sponsorship

I do not have funding/sponsorship

Required

If you have funding/sponsorship, please include the information here

Honorarium: I will request an honorarium to speak

Yes (firm dollar)

Yes (negotiable)

No. I have sponsorship or funding for my proposed presentation.

Please outline your honorarium requirements:

Travel reimbursement: I am requesting expense reimbursement for travel related to this session

Yes

N/A - I have sponsorship for my presentation that includes expense reimbursement.

Please list your estimated expense total and specific coverage (hotel, airfare, etc.)

Conflict of Interest Disclosure Statement. Please select the applicable response below. *

I have either no or inconsequential conflicts of interest.

I have a conflict of interest, as described below.

Required

Detailed description of conflict of interest

Date *

YYYY

Signature *

Send me a copy of my responses.

Submit

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