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Care Partners Series - Speaker Proposal Form
1.
Contact Information
Name
Company
Address
City/Town
State/Province
ZIP/Postal Code
Country
Email Address
Phone Number
2.
Provide your website and/or LinkedIn (if applicable)
3.
Provide your credentials (if applicable)
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)
5.
Provide a brief bio (up to 150 words):
6.
Describe your experience with providing care or services to patients with Ataxia (up to 150 words):
7.
Describe what you want the audience to learn (up to 150 words):
8.
Have you been a speaker on this topic before?
Yes
No
If yes, please list when and where.
9.
Are you interested in other speaking opportunities at support group meetings or conferences?
Yes
No
