LAI Chicago Region Chapter Member Presenter Form

Thank you for agreeing to present to our membership and guests. To properly prepare the promotional pieces needed for marketing your presentation, please complete the form and submit the requested information as soon as possible.

If you have any questions, please contact Executive Director Patti Zikmund for assistance at support@laichicagoregion.org.

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* 1. Please provide your name as you would like it to appear on promotional materials.

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* 2. Will you be a presenter or moderator for this program?

Presenter

Moderator

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* 3. Provide your work title as it should appear in promotional materials:

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* 4. Provide the name of your organization:

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* 5. Please share your email address. We will register you as a speaker for this event, after which you will receive an email confirmation.

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* 6. Phone Number

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* 7. Please select a menu type.

Vegetarian

Vegan

Gluten Free

No special menu required

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* 8. Please list any food related allergies or sensitivities or indicate N/A.

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* 9. What is the date of your program?

Date

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* 10. Please upload a short 3-5 sentence bio.

PDF, DOC, DOCX file types only.

Choose File

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* 11. Please upload your headshot.

PNG, JPG, JPEG file types only.

Choose File

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* 12. May we share your slides with the event attendees in post-event follow up?

Yes

Not Applicable

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* 13. Do you allow yourself to be photographed and for LAI Chicago Region to share your image on the LAI Chicago Region website, social media platforms, and Flickr account?

Yes

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* 14. Please provide the full url to your personal and/or company LinkedIn profile if you give us permission to tag you in a post.

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* 15. LAI Chicago Region strives to host inclusive, accessible events that enable all individuals, including individuals with disabilities, to engage fully. Please list any accommodation requests here or indicate N/A if no accommodations are needed:

We're gathering feedback to help us foster a more diverse, equitable, and inclusive environment. The information you provide below is voluntary and will be kept confidential.

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* 16. Which race/ethnicity best describes you? (Please choose only one.)

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Prefer not to answer

Other (please specify)

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* 17. Which of the following options most closely aligns with your gender?

Woman

Man

Non-binary

Gender not listed

Prefer not to answer

Thank you again. Please feel free to reach out with any questions at support@laichicagoregion.org.