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* 1. Full name with credentials: 

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* 2. Job Title:

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* 3. Organization Affiliation:

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* 4. Email address:

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* 5. State/Region:

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* 6. My story involves the following elements (please check all that apply):

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* 7. Use the space below to describe how you have adapted, evolved and/or thrived in the field of genetic counseling.

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* 8. Describe your level of speaking experience:

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* 9. I grant to NSGC a non-exclusive, royalty-free, reusable, worldwide license to distribute, copy or otherwise publish my Entry Materials to NSGC’s members and attendees at the time of, and immediately after, my entry submission. “Entry Materials” includes all supporting materials to my contest entry (e.g. video, application materials, PowerPoint slides, handouts, etc.) and the audio recordings. NSGC’s publication or distribution of the Entry Materials may be made in hard copy or electronic format, or via posting on NSGC’s website and social media.

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* 10. It is agreed that the NSGC will not be held responsible for royalties or any damages resulting from intellectual property infringement from either (I) NSGC’s use and distribution of the Entry Materials in a manner consistent with this agreement, or (II) any use or misuse of any of the Entry Materials by any person who obtains the Entry Materials (directly or indirectly) as a result of the NSGC’s permitted use and distribution of the Entry Materials.

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* 11. I attest that I am the owner of all content and intellectual property included in my presentation, video and Entry Materials, and, as such, have the right to grant NSGC the above license. If I am not the owner, I will obtain written permission to reprint copyrighted material from the copyright holder.

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* 12. To share your video, please provide the link to your video below, tweet your video tagging @geneticcouns or email your video to speakers@nsgc.org. 

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