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  • AG Bell Symposium Speaker Agreement and Disclosure Form

  • Please complete and sign this form (using your computer mouse) which contains Speaker Agreement information (e.g. video/photo, HIPAA requirements, European requirements), and Speaker Disclosure information required for compliance with AG Bell's policies as well as the American Speech-Language-Hearing Association (ASHA) Continuing Education Board’s requirements. You must complete each section of this form to present at the AG Bell Global Listening and Spoken Language Symposium.

    As the Lead Presenter for your Session, please forward this form to your co-presenters and be sure that each co-presenter knows that they must complete and sign the Speaker Agreement and Speaker Disclosure sections of this form by November 1, 2025.

  • 1. Speaker Agreement Section

  • AGREEMENT (Please complete one form for each presentation AND share this form link with each co-presenter for completion)

    This Agreement is made and entered by and between the Alexander Graham Bell Association for the Deaf and Hard of Hearing and "Presenter" to allow the following presentation to be used as an AG Bell Global LSL Symposium session. In consideration of the terms and provisions below, the parties hereto agree to the following:

  • Dear Presenter:

    Please read and complete the following forms, answer yes/no to all questions, and sign below. Speaker disclosure information, whether financial or non-financial in nature, must be disclosed and publicized in order to list you as the authors of this presentation. This speaker agreement and disclosure information is due November 1, which is well before when you will actually conduct your presentation and is required in order for AG Bell to gain continuing education approval from various organizations.  

    Thank you!

  • A.

    I agree to present this presentation during the AG Bell Global LSL Symposium June 4-6, 2026, on the specific date and time assigned by the Symposium Education Advisory Committee. I am willing to present live and in-person and have my session recorded and shared after the Symposium. I understand and agree to have my name and likeness and information about my presenation shared on AG Bell's websites, e-news and in social media.

  • Please select one:*

  • B.

    I agree to the following terms as a presenter for the AG Bell Symposium: 

    • AG Bell has my permission and is authorized to use my name and likeness and to video, audiotape, photograph, and otherwise record, edit, or otherwise reproduce my presentation and to use it in formats and purposes as stated.
    • Specific to the 2026 Symposium, I am willing to have this session recorded and placed with my name and likeness in the secure learning management system for AG Bell Symposium attendees to view on demand for a nine-week period following the Symposium. 
  • Please select one:*

  • My below signature indicates my permission to have my presentation offered as a session of the 2026 AG Bell Global LSL Symposium and for AG Bell to conduct related activities for the implementation of this agreement.

  • 2. Speaker Disclosure Section

  • Please complete and electronically sign this form related to various privacy and disclosure requirements that apply globally and/or the United States of America.  

  • Program Planner/Instructional Personnel Relationship Disclosure

    In compliance with the American Speech-Language-Hearing Association (ASHA) Continuing Education Board’s Requirements, the Alexander Graham Bell Association (AG Bell) requires program planners and instructional personnel to disclose information regarding any relevant financial and non-financial relationships related to course content prior to and during course planning. Based on the information provided, AG Bell will engage the program planner/instructional personnel in a guided interview process which seeks to understand how the relevant financial or non-financial relationship may influence the content of the course.

  • Relevant Financial & Non-Financial Relationship Disclosures

  • Relevant Financial Relationships

  • Relevant financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, gift, speaking fee, consulting fee, honoraria, ownership interest (e.g., stocks, stock options, or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial relationships can also include “contracted research” where the institution gets the grant and manages the funds and the individual is the principal or named investigator on the grant. Do you have relevant financial relationships to disclose? *
  • If yes, what was received? (Check all that apply)*

  • Relevant Non-Financial Relationships

  • Relevant non-financial relationships are those relationships that might bias an individual including any personal, professional, political, institutional, religious or other relationship. May also include personal interest or cultural bias. Do you have relevant non-financial relationships to disclose? *
  • My relevant non-financial disclosure is related to:*

  • Content Disclosure

  • Course Content Disclosure: All proposals must include a disclosure statement indicating whether course content will focus on a specific product or service, and if information about similar or related products/services will be included. Disclosures must be written in a neutral, non-promotional manner (no sales or advertising). Examples: “This presentation will focus exclusively on [insert product/service name] and will not include information on other similar or related [products/services],” or “This course will discuss [insert product/service name] with limited to no information about comparable products or services.” Proposals submitted without a disclosure statement will be considered incomplete.

  • Does your presentation content focus on any specific product or service and will it include information about proprietary or commercial products?*

  • I attest that the information in this disclosure is accurate at the time of completion and I agree to notify AG Bell of any changes to this information between now and the beginning of the Symposium.

  • Should be Empty: