Webinar Speaker Registration Survey

1. Your Name

Your Name

2. Phone Number

Phone Number

3. E-mail

E-mail

4. Do you have a camcorder or webcam hooked up to your internet on your computer?

Do you have a camcorder or webcam hooked up to your internet on your computer? Yes

5. Date and Time you will be available to speak?

Date and Time you will be available to speak?

6. Please select the topic(s) that best fit the theme of your expertise

Please select the topic(s) that best fit the theme of your expertise ADHD/ADD

Aging Concerns (Heart, prostate, Ortheoporosis, Arthritis)

Asthma

Autism/Autism Spectrum

Colon Cancer

Depression

Diabetes

Dieting Plan (Weight Loss, Anti-inflammation, Allergies)

Health Advocacy & Campaigns

HIV

Inflammatory Bowel (Colitis, Crohn's, Ulcerative Colitis)

IVF

Joint Replacement (Knee/Hip Surgery)

Lung Cancer

Lymphoma (Non-Hodgkins)

Menopause

Pregnancy

Prostate Cancer

Rheumatoid Arthritis

Weight Loss Surgery

Other

7. Area of Expertise/Suggested Theme of Talk/Description of Talk

Area of Expertise/Suggested Theme of Talk/Description of Talk

8. I am 18 years of age or older:

I am 18 years of age or older: Yes

9. Your Location:

Your Location: City
State
Country

10. Do you have Public Speaking experience?

	None	Little	Average	Intermediate	Expert
Scale	Do you have Public Speaking experience? Scale None	Scale Little	Scale Average	Scale Intermediate	Scale Expert

Please specify

11. Add a Link to an example of your most recent Public Speaking event

Add a Link to an example of your most recent Public Speaking event

12. Questions or Comments

Questions or Comments

13. Guidelines:

• Speaker broadcasts are made public on the HealthCentral Channel on Justin.tv, http://www.justin.tv/healthcentral. Viewers participate through watching live, accessing archives, sharing broadcasts, chatting live, posting Q&A’s and commenting on chat.

• You agree not to violate any applicable laws, including intellectual property laws. You indemnify Wellsphere and HealthCentral from any claim, demand, judgment, or other allegation arising from your violation of fair use laws, including any alleged violation of someone's trademark, copyright, or other legally protected interest in your broadcast.

• To the extent you have any direct or indirect interest in any product, treatment, organization or company you discuss or display in your broadcast, you MUST disclose the material terms of that interest in the broadcast. You may not broadcast endorsement, solicitation, commercial, or similar content advocating for or against specific doctors, specific hospitals, specific health practitioners, specific nurses, specific health organizations, specific non-profit organizations, or specific commercial products in a manner implying those entities' methods are fail proof or failure prone. Endorsement or discussion of a product, treatment or company in your broadcast must comply with the FTC’s "Guides Concerning the Use of Endorsements and Testimonials in Advertising"(http://www.ftc.gov/os/2009/10/091005revisedendorsementguides.pdf).

Usage:

By broadcasting a live video, you grant Wellsphere and HealthCentral a perpetual, royalty-free license to use, publish and display your broadcast, in any media, in exchange for acknowledgment such as mention of your name and/or website link in modified videos. No compensation will be paid to any speaker in any manner for participation. You grant Wellsphere and HealthCentral permission to edit, modify, format, or adapt your broadcast at their sole discretion. Wellsphere may contact you for future collaborations such as a Part II to your first broadcast based on viewer feedback.

Guidelines: • Speaker broadcasts are made public on the HealthCentral Channel on Justin.tv, http://www.justin.tv/healthcentral. Viewers participate through watching live, accessing archives, sharing broadcasts, chatting live, posting Q&A’s and commenting on chat. • You agree not to violate any applicable laws, including intellectual property laws. You indemnify Wellsphere and HealthCentral from any claim, demand, judgment, or other allegation arising from your violation of fair use laws, including any alleged violation of someone's trademark, copyright, or other legally protected interest in your broadcast. • To the extent you have any direct or indirect interest in any product, treatment, organization or company you discuss or display in your broadcast, you MUST disclose the material terms of that interest in the broadcast. You may not broadcast endorsement, solicitation, commercial, or similar content advocating for or against specific doctors, specific hospitals, specific health practitioners, specific nurses, specific health organizations, specific non-profit organizations, or specific commercial products in a manner implying those entities' methods are fail proof or failure prone. Endorsement or discussion of a product, treatment or company in your broadcast must comply with the FTC’s "Guides Concerning the Use of Endorsements and Testimonials in Advertising"(http://www.ftc.gov/os/2009/10/091005revisedendorsementguides.pdf). Usage: By broadcasting a live video, you grant Wellsphere and HealthCentral a perpetual, royalty-free license to use, publish and display your broadcast, in any media, in exchange for acknowledgment such as mention of your name and/or website link in modified videos. No compensation will be paid to any speaker in any manner for participation. You grant Wellsphere and HealthCentral permission to edit, modify, format, or adapt your broadcast at their sole discretion. Wellsphere may contact you for future collaborations such as a Part II to your first broadcast based on viewer feedback. I Agree to Terms Described Above.

14. Privacy:

We respect your privacy. Any information you submit to Wellsphere on the registration form will only be used for scheduling, lesson planning, and follow up, and is subject to Wellsphere's Privacy Policy (http://www.wellsphere.com/termsAndPrivacy.s#privacy). We will not disclose, give, sell, or transfer any personally identifiable information about you to any third party without your consent, except as provided in our Privacy Policy (http://www.wellsphere.com/termsAndPrivacy.s#privacy). As your broadcast is publicly available, you should not include personal information about yourself or anyone else that you do not intend to share.

Wellsphere is using Justin.tv to host the broadcasts. You are also subject to Justin.tv's use, privacy, cookie, and security provisions, which can be viewed at http://www.justin.tv/user/terms_of_service.

Privacy: We respect your privacy. Any information you submit to Wellsphere on the registration form will only be used for scheduling, lesson planning, and follow up, and is subject to Wellsphere's Privacy Policy (http://www.wellsphere.com/termsAndPrivacy.s#privacy). We will not disclose, give, sell, or transfer any personally identifiable information about you to any third party without your consent, except as provided in our Privacy Policy (http://www.wellsphere.com/termsAndPrivacy.s#privacy). As your broadcast is publicly available, you should not include personal information about yourself or anyone else that you do not intend to share. Wellsphere is using Justin.tv to host the broadcasts. You are also subject to Justin.tv's use, privacy, cookie, and security provisions, which can be viewed at http://www.justin.tv/user/terms_of_service. I Agree to Terms Described Above.