Speaker Survey Name* First Last Email* PhonePlease provide a title and brief description of the topic you would be interested in speaking on. Please list each (if more than one.)Please provide your credentials, education and expertise to speak at a CAPPA Convention on the topics provided in the previous question.Have you been a CAPPA speaker/presenter in the past?* Yes No If you answered yes to the previous question, please list the locations and year in which you have presented with CAPPA in the past. Indicate N/A if not applicable. What other organizations or associations have you presented for in the past and/or if future plans to present? Indicate N/A if not applicable.Please indicate any organizations or associations you are currently affiliated with, and a brief description of that relationship. Indicate N/A if not applicable.Are you a member of CAPPA?* Yes No If you have presented in the past or currently speak professionally please copy and paste links where we can view blogs, videos, websites, etc.Where are you located and which airport will you typically be travelling in and out of? Why do you feel you will be a good speaker for CAPPA? What will you bring to the CAPPA perinatal professional audience that makes you stand out? To the convention as a whole?Which conference year are you applying to present at? Δ
