Care Partners Series - Speaker Proposal Form Question Title * 1. Contact Information Name Company Address City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * 2. Provide your website and/or LinkedIn (if applicable) Question Title * 3. Provide your credentials (if applicable) Question Title * 4. Please select the category that describes your affiliation: Parent Spouse/Partner Family Member (other than a parent or spouse/partner) Social Worker Mental Health Professional Home Health Care Professional Palliative Care Professional Hospice Care Professional Financial Planning Professional Wellness Professional Other (please specify) Question Title * 5. Provide a brief bio (up to 150 words): Question Title * 6. Describe your experience with providing care or services to patients with Ataxia (up to 150 words): Question Title * 7. Describe what you want the audience to learn (up to 150 words): Question Title * 8. Have you been a speaker on this topic before? Yes No If yes, please list when and where. Question Title * 9. Are you interested in other speaking opportunities at support group meetings or conferences? Yes No Done