ACHIA Speaker Information Form

Please complete and submit by July 23, 2021.

Date

YYYY

Name

First Name

Last Name

Designation

Example: MD, FAAP etc.

Address

City

State

Zip Code

Your Daytime phone number

(###)

###

####

Your Email

Your cell phone number

(###)

###

####

Organization Affiliation

Title

Please provide alternate contact name, phone & email

Title of Topic #1

Learning Objectives

Please list three learning objectives

Title of Topic #2, if applicable

Learning Objectives

Please list three learning objectives

Title of Topic #3, if applicable

Learning Objectives

Please list three learning objectives

Please indicate how you prefer to record your CME module:

Record with ACHIA Staff using Zoom

Record on your own and send a link to ACHIA Staff