Speaker Engagement

First Name *

Last Name *

Position

Organization

Organization Website *

Email *

Contact Phone *

Type of Presentation *

Location of Presentation *

In-person (travel required)

In-person (Greater Vancouver Area)

Virtual (online)

Date of presentation

Is this a pre-recorded presentation? *

Yes

No

Presentation topic

Audiences *

Anticipated number of attendees

Attendee registration fee (if applicable)

Is the presentation being recorded for future use? *

Yes

No

Honorarium provider *

Academic institution

Medical society

Industry

Other (specify)Other (specify)

Honorarium amount

Response requested by *

Do you want to join Dr. Caroline MacCallum's mailing list? *

Yes

No

Title