Care Partners Series - Speaker Proposal Form

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* 1. Contact Information

Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Provide your website and/or LinkedIn (if applicable)

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* 3. Provide your credentials (if applicable)

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* 4. Please select the category that describes your affiliation:

Parent

Spouse/Partner

Family Member (other than a parent or spouse/partner)

Social Worker

Mental Health Professional

Home Health Care Professional

Palliative Care Professional

Hospice Care Professional

Financial Planning Professional

Wellness Professional

Other (please specify)

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* 5. Provide a brief bio (up to 150 words):

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* 6. Describe your experience with providing care or services to patients with Ataxia (up to 150 words):

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* 7. Describe what you want the audience to learn (up to 150 words):

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* 8. Have you been a speaker on this topic before?

Yes

No

If yes, please list when and where.

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* 9. Are you interested in other speaking opportunities at support group meetings or conferences?

Yes

No