IL AFP Speakers Bureau Sign-Up Form

IL AFP Speakers Bureau Sign-Up Form
Name*

First NameLast Name
Credentials (MD, DO, Etc), and/or Title *
Areas of Expertise/Specialty *
Email*
example@example.com
Location*

CityState / Province
Phone Number
Please enter a valid phone number.
I am interested in:*

Being part of a planning committee for an educational activity/projectBeing a speaker for a specific talk (see information below)Being a speaker, and I have experience in public speakingBeing a speaker, but do NOT have experience and would like to be mentoredBeing a mentor
Please list the topics you are most interested and/or areas of expertise.*
If you have a presentation already prepared that you would like the IAFP to consider, please submit the title and length of the presentation. Note that all CME talks must adhere to the IAFP conflict of interest policy
Upload your presentation or abstract if you already have a completed presentation.

Cancelof
Would you be interested in developing KSA workshop curriculum?*

YesNo
Would you be interested in being a KSA workshop speaker with pre-written curriculum material and slides?*

YesNo
CV and/or Head shot photo (optional)

Cancelof
Other information
Thank you for your submission. This information has been added to the Illinois Academy of Family Physicians Speakers Bureau. A member of the IAFP staff will contact you once an opportunity opens.

Any questions, please contact Sara Ortega at sortega@iafp.com
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