Fellows Program: Expertise & Marketing Form

Speaker Candidate Nomination Form

Keystone Symposia is committed to fostering a conference environment that is inclusive of diverse talent, creativity, perspectives, and skill sets. Please assist us in growing our pool of potential speaker candidates by providing the information below. We are particularly interested in nominations of researchers from underrepresented groups (e.g., minority race or ethnicity) as well as scientists from low- and middle-income countries (LMICs). In addition, nominations of early-career scientists from all backgrounds are welcome.
CANDIDATE INFORMATION

Please complete the fields below to the best of your knowledge. Minimally, we are requesting the candidate's name and current affiliation.
Name*

First NameLast Name
Candidate's Institution*
Link to Candidate's Faculty/Lab Website
Candidate's email Address
example@example.com
EXPERTISE

Please select a primary expertise for the candidate from the drop down boxes below. Add keywords to further identify the candidate's background/expertise and include any additional details in comments.
Primary Expertise*
Keystone Symposia is dedicated to engaging diverse voices from around the world in discussions around health disparities and how to rectify these health inequities through scientific research and discovery.

Check this box if the candidate's primary research addresses health equity/disparities.
Keyword 1
Keyword 2
Keyword 3
Please indicate whether Keystone Symposia should also consider this candidate in any of the following leadership capacities:

Organizer (or conference co-organizer)Scientific Advisory Board member
Comments on Expertise/Background
Are you aware of a regularly occuring Keystone Symposia conference topic(s) that fits this candidate's expertise?
Please check all relevant demographics that apply for this candidate, to the best of your knowledge:

Early-stage Investigator (i.e., an investigator who has completed their terminal research degree or end of post-graduate clinical training within the past 10 years and/or an Assistant Professor or equivalent)Member of an underrepresented racial/ethnic group in the U.S. (e.g., African American/Black, Hispanic/Latinx, Native American/Alaska Native, or Hawaiian Native/Natives of the U.S. Pacific Islands)Female scientistOriginates from or resides and works in a designated LMICOther
THANK YOU!

Please complete the fields below if we may contact you regarding this nomination.
Your Name

First NameLast Name
Your Institution
Your email Address
example@example.com
Should be Empty:

Speaker Candidate Nomination Form

CANDIDATE INFORMATION

EXPERTISE

THANK YOU!