MAND 2021 Annual Conference Speaker Application Form
The MAND annual spring conference is tentatively planned for April 2021 in Freeport, Maine. If there is no vaccine for coronavirus, we will switch to a virtual meeting to ensure the safety of everyone.

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 address *
Presenter Name *
Presenter Credentials
Presenter Position/Title
Presenter Organization
Presenter Address
Presenter Phone *
Presenter Academy Membership Number (if applicable)
Please note your professional memberships
Co-Presenter Name (if applicable)
Co-Presenter Credentials
Co-Presenter Position/Title
Co-Presenter Organization
Co-Presenter Address
Co-Presenter Phone
Co-Presenter Email Address
Co-Presenter Academy Membership Number (if applicable)
Please note professional memberships of Co-Presenter
Other professional memberships of Co-Presenter
Please check all that apply: *
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 (http://bit.ly/CDRPI)
Explanation of how your proposed presentation relates to the learning areas you have identified. *
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 *
Required
If you have funding/sponsorship, please include the information here
Honorarium: I will request an honorarium to speak
Please outline your honorarium requirements:
Travel reimbursement: I am requesting expense reimbursement for travel related to this session
Please list your estimated expense total and specific coverage (hotel, airfare, etc.)
Conflict of Interest Disclosure Statement. Please select the applicable response below. *
Required
Detailed description of conflict of interest
Date *
MM
/
DD
/
YYYY
Signature *
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy