AAP Speaker Information Form - 2021 Infectious Disease Course

AAP SPEAKER INFORMATION FORM
2021 AAP Pediatric Infectious Diseases Virtual Course A Comprehensive Review for Primary and Subspecialty Practitioners
Professional Details
Please type your Name, Professional Designation, Academic Title, Institution, City, and State, as you want them to appear in course materials.
Name*
First NameLast Name
Professional Designation (MD, DO, MPH, etc) and Academic Title **Please indicate if you are a FAAP***
Professional DesignationAcademic Title
Contact Information
Please provide the following information for AAP Contact purposes
Name of Your Professional Institution/Organization*
Professional Institution
Institution/Organization Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number*
Please enter a valid phone number.
E-mail*
example@example.com
Headshot Photo - 10800KB File Size Maximum - Acceptable File formats - pdf, doc, docx, jpg, jpeg, png, gif*
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Assistant Name
First NameLast Name
Assistant Phone Number
Please enter a valid phone number.
Assistant E-mail
example@example.com
Sessions - Please Complete the Information For As Many Sessions That You Will Present
Session 1*
ARS (For general session only)General SessionConcurrent Breakout Session
Proposed Session Title for Brochure:*
Session 1
Enter 3-4 Proposed Session Learning Objectives: “Upon Completion of this session, the learner will be better able to...” *
Session 1
Session 2
ARS (For general session only)General SessionConcurrent Breakout Session
Proposed Session Title for Brochure:
Session 2
Enter 3-4 Proposed Session Learning Objectives: “Upon Completion of this session, the learner will be better able to...”
Session 2
Session 3
ARS (For general session only)General SessionConcurrent Breakout Session
Proposed Session Title for Brochure:
Session 3
Enter 3-4 Proposed Session Learning Objectives: “Upon Completion of this session, the learner will be better able to...”
Session 3
Session 4
ARS (For general session only)General SessionConcurrent Breakout Session
Proposed Session Title for Brochure:
Session 4
Enter 3-4 Proposed Session Learning Objectives: “Upon Completion of this session, the learner will be better able to...”
Session 4
Session 5
ARS (For general session only)General SessionConcurrent Breakout Session
Proposed Session Title for Brochure:
Session 5
Enter 3-4 Proposed Session Learning Objectives: “Upon Completion of this session, the learner will be better able to...”
Session 5
Session 6
ARS (For general session only)General SessionConcurrent Breakout Session
Proposed Session Title for Brochure:
Session 6
Enter 3-4 Proposed Session Learning Objectives: “Upon Completion of this session, the learner will be better able to...”
Session 6
NOTE: Please make every effort to provide complete information with correct spelling. This is especially important for a non-FAAP speaker!
Should be Empty: