Speaker Form

YOUR IDEA/STORY

Title of your presentation/story/paper *

Brief abstract (less than 50 words) and/or a research paper abstract *

Upload your high resolution mugshot photo (max size: 1Mb, type: PNG, JPG, GIF)

YOUR SPEAKING ENGAGEMENTS

Please supply us with up to three links to recent speaking engagements *

Please supply us with any recent articles, blogs, social media about you or written by you *

Please tell us about any honours won, awards or prizes (Nobel, Oscar, Tony, Webby, etc.) *

Please supply us with a reference (first name, last name, company, email, phone number) *

YOUR CONTACT INFO

First Name *

Last Name *

Title *

Email *

Company/organization *

Phone *

Mobile *

Address - Street *

Address - City *

Address - Postal code *

Address - Country *

Address - Website *

LinkedIn

Facebook

Twitter

Chose one speaking opportunity *

Other

SPEAKER CONSENT

By uploading materials to INTERFACE Health Summit 2018, you are consenting to the use of those materials (photos, videos, logos, presentations and other documents) by INTERFACE Health Society on the interfacesummit.com or other websites owned by the society in promotional materials and social media before, during ad after the event. Anything you upload remains your intellectual property and will not be used by INTERFACE Health for any other purpose beyond promoting or explaining the INTERFACE Health Summits and related activities.

Please read this speaker consent statement carefully *