HPC - Speaker Registration

HPC - Speaker Registration

Speaker Information

Speaker's Name*

Title

Professional Affiliation

Presentation Topic(s)

Session Preference

Select

Availability

Select

Short Bio*

All speakers must submit a short bio with their registration in the space below. 250 words or less.

Presentation Support

Audio/Visual

Select

Promotion/Advertisement

Would you like your email address published in our program?*

Select

Would you like to place a Half Page Ad in our program?*

Half Page, Black and White Ad.

Artwork can be provided in the File Upload below, or via email to Dr. Camen E. Rexach at crexach@mtsac.edu

Select or enter value

File Upload

Drag and drop files here or

Contact Information

Contact Name*

Email*

Phone*

Phone

Allow Text Messages

Select or enter value

Mailing Address Line 1*

Address Line 2

City*

State*

Zip Code*

Conference Day

Lunch
Science Lab and Museum Tours

Will you be staying for lunch?*

Select or enter value

Do you have any dietary needs?

Tours

Tours of the science labs and museums will be available on the day of the conference.

No Tour

Request a COPY of this Submission

If you have any additional questions or concerns, please contact Dr. Carmen E. Rexach, Mt. San Antonio College, 1100 N Grand Ave., Walnut, CA 91789-1399, or by e-mail to crexach@mtsac.edu, 909-274-4223

Send me a copy of my responses

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