Panelist Application

1
Full Name* This field is required.
First Name
Last Name
2
Email Address* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Short Bio* This field is required.Tell me about yourself!
5
Relevant Experience (e.g., previous talks, panels, or subject expertise)* This field is required.
6
Links to Previous Talks, Publications, or Supporting Materials (if any)
7
Instagram Profile* This field is required.
8
Do you have professional headshots?* This field is required.
Yes
No
9
Industry Niche* This field is required.scroll down
Please Select
Please Select
Nursing
Medicine
Healthcare Worker
Influencer/ Content Creation
Entrepreneur
Mental Health
Financial wellness
Other
10
If you chose "other" please specify
11
Have you attended the Beyond Nursing Summit in the past?* This field is required.
Yes
No
12
Beyond your title or credentials, what legacy are you hoping to leave in your profession or community?* This field is required.
Should be Empty: