Convention Speaker Form

Name

First Last

Initials / Credentials

Phone

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Presentation Title

Honorarium

Yes - I would like to request a speaker honorarium

No - I don't require a speaker honorarium

Speaker Honorarium amount requested

Travel Expense Reimbursement

Yes - I would like to request travel expense reimbursment

No - I don't need travel expense reimbursement

Travel Expense needs: please specify

At this time we fully expect to have all presenters live and in-person, but we fully understand that you may wish to present virtually and live stream into the conference center. We are more than happy to accommodate your wish, let us know if you plan to present remotely so we can make appropriate arrangements.

Presentation Description

Learning Objectives - Participants will be able to:

Bio (describe your qualifications, degree(s) and where earned, and your professional experience):

Clinical (Speech-Language Pathologists)

Schools (Speech-Language Pathologists)

Audiologists

Students Only

General Session for All Audiences

Instructional Level (please mark one of the following levels):

Introductory

Imtermediate

Advanced

Various

Please provide a financial disclosure statement. (Example: John Doe is employed by ABC Corporation).

Please provide a non-financial disclosure statement. (Example: John Doe has no nonfinancial relationships to disclose).

The NSLHA 2024 Fall Conference is Thursday, September 19 thru Friday, September 20, 2024, at the Younes Convention Center North / Crowne Plaza Hotel in Kearney, NE.

2024 Convention Speaker Form

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