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Piedmont Speakers Network
Speaker Information Form
Please take a moment to tell us about you and what you're passionate about! We have many educational activities throughout the year and across the system and one might just be the perfect fit for you and your expertise.
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1.
What is your profession?
APRN
Athletic Trainer
Dietitian
Nurse
PA
Pharmacist
Physician
Psychologist
Social Worker
Other (please specify)
2.
What is your specialty/areas of interest?
3.
The topic(s) I am interested in presenting include:
Topic 1
Topic 2
Topic 3
Topic 4
Topic 5
Topic 6
4.
Would you be interested in any of the following? In addition to the actual activity, a post-test, rationale for answers, and references/resources for further study would also need to be provided.
Podcasts
Recorded lectures
Narrated powerpoints
Printed materials
Other (please specify)
5.
Which facility/facilities are you able to present at? (Check all that apply)
Piedmont Athens Regional
Piedmont Atlanta
Piedmont Augusta
Piedmont Cartersville
Piedmont Clinic
Piedmont Columbus Regional
Piedmont Eastside
Piedmont Fayette
Piedmont Henry
Piedmont Macon
Piedmont Mountainside
Piedmont Newnan
Piedmont Newton
Piedmont Rockdale
Piedmont Walton
Other (please specify)
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6.
Your information
(Required.)
Name
*
Professional Credentials
*
Email Address
*
Phone Number
Current Progress,
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