*1.Full Name, including credentials (ex: Jane Doe RN, MSN, IBCLC):(Required.)

2.Contact Address:

Name and/or Agency:

Street:

Street:

City:

State:

Zip Code:

*3.Phone Number:(Required.)

*4.Email Address:(Required.)

5.Additional information about credentials and/or qualifications:

*6.List your area(s) of Subject Matter Expertise you are willing to be contacted about:(Required.)

7.Title(s) of Possible Presentation(s):

1

2

3

4

5

*8.Check the audience(s) you would be willing to present to:(Required.)

Physicians

Nurses

Social Workers

Patients/Families

Community organizations

Students

Other (please specify)

9.Do you require an honorarium?

Yes

No

Other (please explain)

*10.Please tell us what you're available for:(Required.)

Presentations 

Trainings

Referrals

Consultation

Other (please specify)

11.Please check the counties you would be willing to travel to:

Atlantic 

Burlington

Camden

Cape May

Cumberland

Gloucester

Salem

All of South Jersey