Speaker Application for 2025 Symposium January 15, 2025 Speaker/Proposal Submission This form is intended to be submitted by the speaker. The form may be used as a general request to be a speaker, or to submit specific topics to present as the speaker. Your Personal InformationYour Name(Required) First Last Credentials(Required)AARC Number (if applicable)Your Email Address(Required) Enter Email Confirm Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Your Phone(Required)Best Contact Method(Required)What is the best way to contact you about your submission?CallTextEmailNo preferenceAreas of ExpertiseSelect all that apply.Specialty Area(s)Select all that apply. Adult Acute Care Ambulatory & Post Acute Care Critical Care Transport Diagnostics Education Leadership & Management Neonatal/Pediatrics Sleep Other Knowledge Area(s)Select all that apply to your areas of expertise. Aerosol therapy Airway management ARDS Chronic respiratory disease Ethics Extracorporeal life support General critical care Interventional pulmonology Mechanical ventilation Mental health Pulmonary function Sleep disorders Rehabilitation Other Describe OtherMore About YouTell Us About Yourself(Required)Give a brief description of your lecture, points of interest, your background on the topic and any other pertinent information.Upload a headshot hereMax. file size: 64 MB. Conflict of Interest(Required) An individual involved in the planning of, or presentation of, an education activity may have an interest in or affiliation with an organization, but the audience must be informed of this relationship before the presentation of the activity. For this purpose, a real or apparent conflict of interest is defined as personal gain or benefit derived from involvement with any entity, product or service. Vested Interest includes (but is not limited to) employment, by owning stock, from inclusion in a speakers’ bureau or a relationship, personal or otherwise, with a company that could potentially benefit from the relationship. I recognize that I must follow all criteria regarding vested interest and declare that: MARK ONLY ONE. I have NO conflicts of interest I HAVE a conflict of interest Conflict of Interest Disclosure StatementWith whom do you have conflict of interest? Post navigation Previous Previous post: 2025 MeetingsNext Next post: SPECIAL DELEGATE ELECTION!!
