Ascend Convention - Speaker Intake Form

Ascend Convention - Speaker Intake Form
Name (as it should appear in the official conference program)*

First NameLast Name
Professional/Job Title/Role*
Organization | Company*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Assistant or Administrator's Name (if applicable)
Email of Assistant or Administrator
example@example.com
Phone Number

Area CodePhone Number
Biography (100 word maximum)*

0/100
High Resolution Headshot*

Please submit a high resolution (300 dpi or higher, JPG format, PNG format) professional headshot to be used in the convention
Cancelof
Inspiration quote or fun fact about yourself
Please share one convention tip with our attendees
Mailing address (optional)
*Your shipping address may be used to ship materials related to the specific event you are participating in. It will not be used for other purposes outside of the said event.
Social Media Information for the Organization(Optional)

Please provide information in this section if you would like to be included in cross-promotion opportunities
Facebook handle/username (optional)
LinkedIn handle (optional)
Instagram handle (optional)
Twitter handle (optional)
I give consent for:*

Photo OnlyVideo OnlyBoth Photo and Video
Media Waiver

I hereby grant Ascend permission for up to a 12-month period to use my image and likeness captured during all Ascend National Convention activities to be used solely for the purposes of Ascend promotional material and publications and waive any rights of compensation or ownership thereto.
If at any time you have questions, please contact the

Convention Management office at NCplanner@ascendleadership.org
Should be Empty:

Ascend Convention - Speaker Intake Form

Social Media Information for the Organization(Optional)

Media Waiver