AACN Chapter Speaker Request Form for In-Person & Virtual Meetings

AACN Chapter Speaker Request Form for In-Person & Virtual Meetings

IMPORTANT! AFTER YOU CLICK SUBMIT, a copy of your responses will be sent to you via the Primary Contact email you enter on this form.

Chapter Name*

List full name

Primary Contact Name*

Primary Contact Cell Number*

Include area code

Primary Contact Email Address*

Is primary contact the Meeting Facilitator?*

Yes

Meeting Facilitator Name

Meeting Facilitator Cell Number

Meeting Facilitator Email

Event Title*

Event Date*

Is event date set or flexible?*

Set

Flexible

First choice option

Second choice option

Third choice option

Event Type*

Select

Speaker Connection Information

If Chapter cancels the event, they are to immediately notify the Home office at 800.394.5995, ext. 365. If the Speaker needs to cancel, the Home office will immediately notify the Primary Contact and/or Meeting Facilitator and assist in finding a replacement speaker, if possible.*

I acknowledge Cancellation Policy

Keynote Speaker Name*

Select

Adamski Keynote Topics

Select

Marsh Keynote Topics

Select

Davis Keynote Topics

Select

Ellis Keynote Topics

Select

Berndt Keynote Topics

Select

Scruth Keynote Topics

Select

Keynote Virtual Visit

Briefly describe the type of virtual visit you are requesting

Presentation Time*

Indicate AM or PM and Time Zone

Presentation Duration*

Specify desired length of time (example: 60 minutes)

Breakout Speaker Name

Select

Adamski Breakout Topics

Select

Marsh Breakout Topics

Select

Davis Breakout Topics

Select

Ellis Breakout Topics

Select

Berndt Breakout Topics

Select

Scruth Breakout Topics

Select

Breakout Virtual Visit

Briefly describe the type of virtual visit you are requesting

Breakout Presentation Time

Indicate AM or PM and Time Zone

Breakout Presentation Duration

Specify desired length of time (example: 60 minutes)

The Speaker's presentation materials are meant to copy/provide for the sole purpose of giving to the attendees of this event. They may not be copied, sold or given away for any other purpose without expressed written permission of the Speaker*

I acknowledge Copyright

Individual Disclosure & Mitigation Form - Click here to download the form:*

https://www.aacn.org/nursing-excellence/chapters/aacn-chapter-speaker-request-form

I acknowledge IDM

Recording of Presentation - Written permission is required from the Speaker, prior to the event, if the Chapter wants to record the session to post on their website, social media accounts, etc., for the purpose of other chapter members viewing at a later date, to get the CEs (if the chapter obtains CEs). This is referred to as providing enduring contact hours, and the Nurse Planner must note this in their CE application. Click here to download the Speaker Consent for Recording Form.*

https://www.aacn.org/nursing-excellence/chapters/aacn-chapter-speaker-request-form

I acknowledge Policy

Additional Comments

Privacy Notice|Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.