NDA 2024 Annual Conference

2024 Annual Conference

CALL FOR CLINICS
October 2 - 4, 2024
DEADLINE: March 31, 2024

NOTE: These forms MUST be fully completed in order for a clinic to be considered. Any partially completed forms will be returned and will not be considered until fully completed. Completed forms MUST be returned along with a clinic description, presenter(s) bio and presenter(s) headshot attached.

Questions while completing this form can be directed to Shelly Joines at sjoines@executiveoffice.org or (850) 205 - 5634.
Speaker Name*

First NameLast Name
Credentials (certifications, degrees, etc)

Presenter Information
Speaker Bio:

Cancelof
Speaker Bio: *
Type "See above" if previously uploaded.
Speaker Address (for contracting & communication)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Speaker Phone Number*
Please enter a valid phone number.
Speaker E-mail*
example@example.com

Sponsor Information

NDA is unable to cover Honorarium or travel expenses. Expenses related to a speaker's participation are the responsibility of the speakers or sponsoring organization.
Do you have a sponsor secured for this presentation?*

Yes, they are listed below.No, I need to secure one.No, I don't require a sponsor.
Sponsoring Organization:*
(List N/A if appropriate)
Sponsor Contact Name:

First NameLast Name
Sponsor E-mail:
example@example.com
Sponsor Phone:
Please enter a valid phone number.

One last thing!
Name of individual completing this form if not speaker:

First NameLast Name
E-mail for individual completing this form if not speaker:
example@example.com
Should be Empty: