BCPH Speaker Bureau Directory Inclusion
Primary Email
*
example@example.com
Alternative Email
*
example@example.com
Name
*
First Name
Last Name
Pronouns
*
Example: She/Her/Hers
State
Postal code search
Country of Residence
*
Country of Origin
*
Title
*
MD/DO
ScD/SD/DSc
PhD
JD
MA
MS/MPH
Other
Current position (Student/Professor/Director of Research, etc. If none, enter "N/A")
*
Organizational Affiliation (If none, enter "N/A")
*
Area(s) of public health/health and social justice focus (Select all that apply.):
*
Health policy
Health management
Maternal and Child Health
Reproductive and sexual health
LGBTQ+ Health
Men's Health
Women's Health
Substance Use, Abuse, and Addiction
Refugee/Immigrant Health
Infectious diseases
Environmental health
Occupational health
Dental Health
Global Health
Disability
Other
Brief Professional biography (must be written in the THIRD person and not extend beyond 4 sentences)
*
Why do you want to be included in the BCPH Lyons's Speaker Bureau Directory?
*
Other Media Appearances (500 words MAX)
*
Upload your CV
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload previous speaking engagements (Youtube URLs, videos, etc.)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Professional Headshot (will not accept copies of driver licenses, passports)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
LinkedIn URL (required because BCPH promotes verifiable professionals)
*
Other relevant links and information:
Are you a member of the Boston Congress of Public Health? The Award is a benefit to members only. You may apply without a membership, but if awarded, a membership must be purchased at that time.
Yes, I am a BCPH Elite Member.
No, I am not a BCPH Elite Member - disqualified application.
Demographics
Below are some background questions that help us tailor our programming and ensure that we are meeting our mission for diverse representation and celebration of all people. However, you are not obligated to answer.
Gender: I identify as (click all that apply):
Man
Woman
Non-Binary
Trans gender
X
Other
Race: I identify as (click all that apply):
White
Black or African American
Asian
American Indian and Alaska Native
Native Hawaiian and Other Pacific Islander
Multiracial/Biracial
Other
I am /was the first person in my family to go to college.
Please Select
Yes
No
Age
Under Age 18
18-21
22-25
26-29
30-34
35-39
40-44
45-49
50-54
55-59
60+
Please verify that you are human
*
Payment
Registration Payment
*
prev
next
( X )
Non-Refundable Application Fee
$
5.00
Today's Date
*
-
Day
-
Month
Year
Date
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Print Form
Save
Submit
Clear Form
Should be Empty: