Speaker Registration

2024 MSCHWA Speaker Form

Please complete the 2024 Speaker form for the MSCHWA.

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Name

First

Last

Cell Phone Number

Please check whether you agree to speak for the 2nd Annual MSCHWA Summit!

Yes! I am confirming my availability to speak!
No, I regretfully decline this speaking opportunity.

If you are confirming, please continue to complete the form. If you are declining, submit this form with just your name & email and the checkbox that you decline.

Credential and Title

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Resume

Click or drag a file to this area to upload.

Please no more than 4 pages.

Headshot

Click or drag a file to this area to upload.

Professional Headshots ONLY

Bio

Click or drag a file to this area to upload.

1 page Bio

Please list any presence or absence of relevant financial relationships for any content provided during the presentation.

Need Hotel Accommodations

Yes I need hotel accomodations!
No, I am local and do not need hotel accommodations.
No, my agency is covering my hotel arrangements.

Need Travel Accommodations

Yes I need travel accomodations!
No, I am local and do not need travel accommodations.
No, my agency is covering my travel arrangements.

By signing below, I, the speaker, agree to arrive promptly for my speaking engagement(s) at the Mississippi Community Health Workers Association (MSCHWA) Summit, submit my presentation materials by May 30th, 2024, bring a backup copy of my presentation, and present to the best of my abilities. I also understand that if I am unable to attend, it is my responsibility to notify the summit planner immediately.

I agree

If you are unable to attend, we ask that you please assist with finding a suitable replacement.

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