Please provide the following information:

After you have completed the form, click the SUBMIT button at the bottom of the page. You should see a thank-you message below when your information has been successfully transmitted.

Name of person completing this form *
Name of person completing this form
in case we have any questions
If possible, please limit this to one title. Additional titles and credentials can be included in the brief biography.
If photo link is not available, please email a photo to The photo should be in jpg or png format, at least 200 KB.
as it should appear on postal mail
in case we need to be in contact while in transit
Select the meals that the speaker will be attending
if the speaker will be staying for any meals during the program