submit a speaker proposal

If you would like to be considered as a potential speaker for any of our future events, please fill out the following information:

Name *
Name
Address *
Address
Phone *
Phone
Fax
Fax
Do You Have Any Recorded Presentations Available for Review on the Web? *
Proposed Presentation
PLEASE READ THE FOLLOWING AND INDICATE YOUR ACCEPTANCE BY CHECKING THE BOX BELOW:
IMMH RESERVES THE RIGHT TO COPY, PRINT, AND DISTRIBUTE THE CONFERENCE POWERPOINT SLIDE PRESENTATIONS AS PART OF THE PROGRAM SYLLABUS WHICH WILL BE PROVIDED TO CONFERENCE ATTENDEES. I FURTHER ACKNOWLEDGE THAT COMPILATIONS OF THESE MATERIALS MAY BE SOLD OR PROVIDED FREE OF CHARGE BY THE EVENT PRODUCERS AND OWNERS OF THIS CONFERENCE, AND ITS SUCCESSORS TO REGISTERED ATTENDEES OF THESE EVENTS AND OTHER INDIVIDUALS. IN ADDITION, IMMH RETAINS THE ABILITY TO RECORD AUDIO AND VIDEO OF THE PROGRAM TO ARCHIVE OR USE FOR EDUCATIONAL OR PROMOTIONAL PURPOSES. I HEREBY GIVE MY PERMISSION TO THE EVENT PRODUCERS AND OWNERS AND THEIR SUCCESSORS, THEIR AGENTS, AND REPRESENTATIVES TO RECORD AND DISTRIBUTE AUDIO TAPES, PHOTOGRAPHS, VIDEOS, AND ANY OTHER MEDIA THAT CONTAIN ALL OR A PORTION OF ANY PRESENTATIONS I GIVE, PAPERS I PRESENT, MATERIALS I DISTRIBUTE, AND PANEL DISCUSSION IN WHICH I PARTICIPATE IN AT THIS EVENT WITHOUT ANY OBLIGATION OF THE CONFERENCE OWNER TO PAY ME FEES OR ROYALTY.
I Hereby Agree to the Above Presenter Disclosure and to Abide by the Deadlines as Outlined in the Call for Presentations by Checking the Box Below: *