Speaker Application

  • (Please select all that apply)
  • (Please select all that apply)
  • Please provide a brief summary (80 words or less) of your proposed session.
  • Objectives

    Please provide at least two objectives for the attendees of your presentation. List the attendee’s objectives in behavioral terms (Opens in new tab). (What the attendee takes away from the presentation)





  • First Presenter Information

  • (if applicable)
  • (Required for all presenters, incomplete applications will not be considered)
  • (A brief paragraph for each speaker to be used for introductions in 50-100 words.)
  • Second Presenter Information

  • (if applicable)
  • (A brief paragraph for each speaker to be used for introductions in 50-100 words.)
    • - CV/Resume- for each speaker *
    • - Reference List/Bibliography page- in APA format *
    • - Conflict of Interest form – for each speaker. If you have not already downloaded and completed the Conflict of Interest form, click here to download.*
    • - Speaker Headshot(s) (Will be mandatory to submit upon speaker selection)
      • + Upload must total 128 MB or less and no more than six (6) files can be uploaded
      • + Allowed document file types: pdf, doc
      • + Allowed image file types: jpg gif png
    • - Any other relevant documents
    Drop files here or
    Accepted file types: jpg, gif, png, pdf, doc.
  • This field is for validation purposes and should be left unchanged.
Eisenhower Center
Special Tree
Community Connections
rainbow_logo
Lightouse Neurological Rehabilitation Center