Piedmont Speakers Network

Speaker Information Form

Please take a moment to tell us about you and what you're passionate about! We have many educational activities throughout the year and across the system and one might just be the perfect fit for you and your expertise.

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* 1. What is your profession?

APRN

Athletic Trainer

Dietitian

Nurse

Pharmacist

Physician

Psychologist

Social Worker

Other (please specify)

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* 2. What is your specialty/areas of interest?

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* 3. The topic(s) I am interested in presenting include:

Topic 1

Topic 2

Topic 3

Topic 4

Topic 5

Topic 6

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* 4. Would you be interested in any of the following? In addition to the actual activity, a post-test, rationale for answers, and references/resources for further study would also need to be provided.

Podcasts

Recorded lectures

Narrated powerpoints

Printed materials

Other (please specify)

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* 5. Which facility/facilities are you able to present at? (Check all that apply)

Piedmont Athens Regional

Piedmont Atlanta

Piedmont Augusta

Piedmont Cartersville

Piedmont Clinic

Piedmont Columbus Regional

Piedmont Eastside

Piedmont Fayette

Piedmont Henry

Piedmont Macon

Piedmont Mountainside

Piedmont Newnan

Piedmont Newton

Piedmont Rockdale

Piedmont Walton

Other (please specify)

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* 6. Your information

Name *

Professional Credentials *

Email Address *

Phone Number