Harrisonburg, Virginia

The meeting will take place on October 5th and 6th, 2022

Question Title

* 1. What is the title of your presentation? (Complete one form per title)

Question Title

* 2. What is the topic of your presentation? (Select all that apply)

Question Title

* 3. Briefly describe your presentation. 

Question Title

* 4. What is the length of your presentation?

Question Title

* 5. What is the format of your presentation?

Question Title

* 6. Equipment Needs: Check all that apply

Please note: Only PC Compatible Presentations will be accommodated. 

Question Title

* 7. Are you playing a video or movie?

Question Title

* 8. 1st Speaker's Contact Information

Question Title

* 9. I confirm that I have contacted my co-presenters for their consent in participation and affirm that all subsequent presenters have agreed in advance of submission.

Question Title

* 10. Should someone instead of the speaker be contacted? If so, enter the person's information here.

Question Title

* 11. 1st Speaker's Introduction. Describe how your current position, background, expertise, and topic are relevant to this audience. You may wish to include a little information about your personal interests or other icebreaker (what would you be doing if you didn’t do the work you have now, favorite music, etc.…) to introduce yourself to the audience.

Question Title

* 12. Reference: If you were referred to be a speaker, please list the reference.

Question Title

* 13. 1st SPEAKER: PRESENTATION RELEASE FORM

I, the undersigned, hereby authorize the National Organization of State Offices of Rural Health (NOSORH) to duplicate and distribute my presentation(s) to the NOSORH community and the general public by various means, including, but not limited to, CD, audio cassette, DVD, videotape and via the Internet for purposes consistent with NOSORH’s mission.

I authorize NOSORH in perpetuity to use text, audio, video, and other media from my presentation(s), as well as my name, my physical likeness, voice, and any photographs, film, audio tape, video tape and/or digitized images of me and/or my presentation(s) in any NOSORH online venue and in any other educational/marketing materials prepared and distributed by NOSORH.

I understand and agree that NOSORH makes no warranties or promises regarding unauthorized use by others and that the organization is not responsible for any unauthorized use of text, audio, video, and other media from my presentation(s) by any person, and I agree to hold NOSORH harmless from all such uses. I promise that I either exclusively own all rights, title, and interest in all materials used in my presentation(s) or have obtained prior written authorization to use someone else's copyrighted material. I agree to defend and to hold NOSORH harmless from any and all claims of copyright violation resulting from the use of my presentation materials.

By signing your full name and date below, you are indicating that you have read and agree to the terms and conditions of the Presentation Release Form.

Question Title

* 14. 1st SPEAKER: PHOTOGRAPHY AND PUBLICITY CONSENT RELEASE FORM

I hereby give the National Organization of State Offices of Rural Health (NOSORH), its employees and its agents permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made in conjunction with NOSORH activities.

I agree that NOSORH has complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with NOSORH’s mission. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet.

I acknowledge that I will not receive any compensation, etc for the use of such pictures, etc., and hereby release NOSORH, its employees and its agents from any and all claims which arise out of or are in any way connected with such use.

By signing your full name and date below, you are indicating that you have read and agree to the terms and conditions of the Photography and Publicity Consent Release Form.

The Following Questions are for a secondary speaker.

Question Title

* 15. 2nd Speaker's Contact Information

Question Title

* 16. If not 2nd speaker, who should be contacted?

Question Title

* 17. 2nd Speaker's Introduction. Describe how your current position, background, expertise, and topic are relevant to the work of the audience. You may wish to include a little information about your personal interests or other icebreaker (what would you be doing if you didn’t do the work you have now, favorite music, etc.…) to introduce yourself to the audience.

What to expect: Session selections for the NOSORH Annual Meeting are made by recommendation of the planning committee, comprised of State Offices of Rural Health. If your proposal is accepted, you will be notified approximately 3 months in advance of the meeting. It is your responsibility to ensure your registration, hotel reservation, and forms are completed 4 weeks in advance of the meeting. It takes considerable time to coordinate all the details to produce a successful meeting and your cooperation is appreciated.

T