NHMA Chapter Event Planning Form

Event Name *

Event Description (300 words max) *

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Upload a copy of a completed or working event agenda

Event Date *

Event Time *

Hour Minutes

AM/PM Option

Until

until

Hour Minutes

AM/PM Option

Estimated number of attendees *

Are your requesting CME accreditation for this event? If yes, please contact ygreen@nhmamd.org for additional information and requirements.

Yes No

Does your event feature guest speakers?

Yes No

If yes, please list each speaker (including full name/credentials/title) below.

Please upload headshot photos for all speakers.

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NHMA Programs — Please select the following topics (if any) that plan to be presented or discussed during your meeting: *

Vaccinations Research/Clinical Trials HIV/AIDS Influenza Infectious Diseases Mentoring None of the above Other

Are you requesting NHMA support to arrange a venue for this event? If no, please provide event location (please include address, parking, and security details): *

Yes No

Are you requesting shipping support? *

Yes No

Room set-up options:

Rounds Crescent Rounds Lecture/Classroom Other

Set-up date (if needed):

Date

Set-up needs to be completed by:

Date

Breakdown date (if needed):

Date

Are there any additional meetings planned or in progress that NHMA should be aware of? If so, list all meetings that will occur within the next 3 to 6 months. *

No Yes

NHMA Chapter Event Planning Form

Contact Information

Event Logistics

Catering

Marketing and Communications