KHCA/KCAL Speaker Proposal Form

Please complete the following questions:

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* 1. Presenter Name:

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* 2. Presenter Organization:

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* 3. Presenter Title:

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* 4. Email:

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* 5. Phone Number:

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* 6. Address:

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* 7. Will you present at (check all that apply):

Conferences – as keynote

Conferences – as breakout session

Independent Educational Program

Online webinar

Other (please specify)

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* 8. Presentation title:

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* 9. Please select the length of your session

50 Minutes

75 Minutes

90 Minutes

Other (please specify)

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* 10. Presentation description. (This should be written as if an attendee is deciding if they should attend your session.)

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* 11. Presentation learning objectives. (ie at the end of this session the learner will:)

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* 12. Presenter biography: (for online/printed materials)

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* 13. Please briefly discuss your honorarium request or fee. (presentations requesting fee higher than 5k will not be considered)

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* 14. Upload your photo (optional, but if selected we will required a photo):

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.