Sepsis Alliance Speaker Request

Filling out this form does not guarantee a speaker. Sepsis Alliance will try to accommodate reasonable speaker requests, but there is not always a speaker that matches the criteria or a speaker available.

Please submit all requests at least 4 weeks in advance.

Please allow 3-5 business days for a response from Sepsis Alliance. If you have any questions, please email info@sepsis.org.

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* 1. Name of organization submitting request:

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* 2. Coordinator/point of contact name:

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* 3. Coordinator/point of contact email:

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* 4. Event name/title:

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* 5. Event location:

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* 6. Event date and time:
If undecided, fill in preferred date and time.

Date / Time

Date

Time

AM/PM

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* 7. Event description:

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* 8. Event website (if applicable):

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* 9. Please describe the type of speaker you are looking for (i.e. nurse, physician, sepsis survivor, family member of sepsis victim):

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* 10. What topics would you like the speaker to cover?

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* 11. How much time do you have allotted for the speaker?

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* 12. Expected attendance:

Less than 20

21 - 50

51 - 100

101 - 500

More than 500

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* 13. Is a travel stipend offered?

Yes

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* 14. Is there an honorarium?

Yes

Sepsis Alliance Speaker Request

Question Title

* 1. Name of organization submitting request:

Question Title

* 2. Coordinator/point of contact name:

Question Title

* 3. Coordinator/point of contact email:

Question Title

* 4. Event name/title:

Question Title

* 5. Event location:

Question Title

* 6. Event date and time:
If undecided, fill in preferred date and time.

Question Title

* 7. Event description:

Question Title

* 8. Event website (if applicable):

Question Title

* 9. Please describe the type of speaker you are looking for (i.e. nurse, physician, sepsis survivor, family member of sepsis victim):

Question Title

* 10. What topics would you like the speaker to cover?

Question Title

* 11. How much time do you have allotted for the speaker?

Question Title

* 12. Expected attendance:

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* 13. Is a travel stipend offered?

Question Title

* 14. Is there an honorarium?

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* 15. If yes, what is the honorarium amount offered?

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* 16. Is there anything else we should know about this speaking opportunity?

Sepsis Alliance Speaker Request

Question Title

* 1. Name of organization submitting request:

Question Title

* 2. Coordinator/point of contact name:

Question Title

* 3. Coordinator/point of contact email:

Question Title

* 4. Event name/title:

Question Title

* 5. Event location:

Question Title

* 6. Event date and time:If undecided, fill in preferred date and time.

Question Title

* 7. Event description:

Question Title

* 8. Event website (if applicable):

Question Title

* 9. Please describe the type of speaker you are looking for (i.e. nurse, physician, sepsis survivor, family member of sepsis victim):

Question Title

* 10. What topics would you like the speaker to cover?

Question Title

* 11. How much time do you have allotted for the speaker?

Question Title

* 12. Expected attendance:

Question Title

* 13. Is a travel stipend offered?

Question Title

* 14. Is there an honorarium?

Question Title

* 15. If yes, what is the honorarium amount offered?

Question Title

* 16. Is there anything else we should know about this speaking opportunity?

* 6. Event date and time:
If undecided, fill in preferred date and time.