Speaker Request Form
RequiredRequired Question(s)
Arizona HIMSS is always looking for quality speakers to educate our members.  If you are interested in being a speaker, please fill out the following form.  Please keep in mind that we only allow presentations that are educational in nature.  We do not allow sales presentations.  All presentations will need to be pre-approved. Thanks for your support!

 
1.
Speaker Information:

First Name:
Last Name:
Job Title:
Company Name:
Work Phone:
Email Address:
emailaddress@xyz.com
State/Province
(US/Canada):

2.

Provide a brief speaker bio:

 

1000 characters left.
3.

Will there be a co-presenter? If yes, please provide their name, title, email address and a brief bio. 

 

350 characters left.
4.
Topic of presentation:
Clinical & Business Intelligence
Connected Health
Health Business Solutions
HIT User Experience
Innovation
Interoperability & Health Information Exchange
Informatics
Privacy & Security
Public Policy
Quality, Cost and Safety
Professional Development
Other  
Required 5.

Presentation Title

 

350 characters left.
Required 6.

A synopsis of the material to be presented:

 

1000 characters left.
7.
Does this speaker require a speaker fee or travel costs be covered?
Yes
No
8.

Is your organization willing to sponsor the fees and/or travel costs for this speaker?

Yes
No
9.

Your name:

 

50 characters left.
10.

Your Title:

 

50 characters left.
11.

Your organization:

 

50 characters left.
12.

Your email:

 

50 characters left.
13.

Your phone number:

 

50 characters left.