Department of Continuing Medical EducationLive SymposiaSPEAKER CONFIRMATION FORM Please complete the following form as soon as possible so that we may adequately prepare for your presentation. If you login to your iLearn account before completing, you will be able to save your progress and return to submit the form at a later time. Select the conference you are participating in * GPRSA (General Pediatrics Review & Self-Assessment PHMSA (Pediatric Hospital Medicine Review & Self-Assessment) Speaker Details Upload a recent CV Your CV will be used for administrative purposes only and will not be shared with the audience.Files must be less than 2 MB.Allowed file types: pdf doc docx odt. Please provide a phone number where we can reach you on the day of the conference. This number will be used for emergencies only in the event you fail to arrive at the scheduled time. You can also provide alternate emails for us to send you speaker documentations, reminders, and/or other communications. Phone Number * Alternative Email Would you like us to tag you directly on our social media advertisement campaign? * Let us know if you'd like to be tagged in any of our posts about the conference. If yes, please enter at least ONE of your social media handles. (If you do not have any social media accounts, we may will still mention you by name) Yes No Twitter Instagram Facebook Presentation Details Presentation Date * Select the date your presentation is scheduled for Thursday, May 12, 2022 Friday, May 13, 2022 Saturday, May 14, 2022 Sunday, May 15, 2022 Additional Presentations I will be presenting multiple times in this conference If you are presenting more than once, please send any additional titles and objectives via email to cme@nicklaushealth.org. You will need to provide at least 3 objectives per talk. Presentation Title * Learning ObjectivesPlease provide at least 3 learning objectives for your presentation. Objective 1 * Objective 2 * Objective 3 * Add additional objectives? Select this option to add a fourth or more objectives. Make sure to number any additional objectives. Yes Objective 4+ * I plan to include the following elements in my presentation: * Video Playback WITHOUT Audio (I plan to play a silent video in my presentation) Video Playback WITH Audio (I plan to play a video with audio in my presentation) Audio playback (I have audio in my presentation) Audience Response System (such as Poll Everywhere or Slido) Other (please describe)... I plan to include the following elements in my presentation: Other (please describe)... By entering my name below I agree to submit my slides in a timely fashion by the requested deadline and complete any additional requested forms via the iLearnPeds.com platform. * email * If you are logged in, your iLearn profile email will be entered as default. If you are not logged in or do not have an iLearnPeds.com account yet, please enter the email you intend to use when registering your account Leave this field blank
