Speaker Registration Form
Summit Speaker Request for ProposalThank you for your interest in becoming one of our 2015 Worksite Wellness Summit Speakers! Below is our Request for Proposal form to collect specific pieces of information that will help us with our selection process.
Please fill out the form below, and upon submission, you will receive a confirmation email. You may need to check your spam folder, just in case.
All RFPs are due by 5/1/15. We will review the submissions and will get back to you with any questions and follow up by 5/15/15.
* Please submit one RFP per topic you are interested or able to speak to.*0This form works best with Chrome, Safari and Firefox. Older versions of Internet Explorer may not work properly.1Contact Information2First Name*3Last Name*4Company*Name of your employer5Job Title*Your position within the company6Address*Street7City*8State*select your stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonMarylandMassachusettsMichiganMinnesotaMississippiMissouriPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming9Zip*10Phone*11Email*your valid email address12Biography & Experience13Your Biography*Write a brief bio about yourself (150 words)14Speaking Experience*Read the instructions for more details (150 words)15Video URL Link*(YouTube or Vimeo link if applicable)16Breakout Session Presentations17The Break-Out Sessions are designed to provide relevant content to participants, as well as opportunities to be hands-on with the content and interact with one another about the topic. The Break-Out Sessions should be interactive and participatory. The sessions will include a 30-minute presentation directly followed by 30-minutes of facilitated activities that build from ideas shared during the presentation.
Please select which of the following wellness topics your presentation relates to:18Breakout Session Presentation Topics*select one or moreBranding your Wellness ProgramEffective Use of BiometricsIncentive Management – Intrinsic v. ExtrinsicPolicies Concerning WellnessCorporate MindfulnessOtherCase Studies19Your Topic*Title of your presentation20Description*Write a brief presentation overview (150 words)21Breakout Session Presentation Elements:*What elements does your presentation include?Case study(s)5-10 minutes activity break mid-sessionHandouts or materialsSufficient time for Q & ASmall group interaction exercise based on the content presented22Refererences23Reference #1*First and Last Name24Phone*Contact Number25Email*Reference #1 email26Reference #2*First and Last Name27Phone*Contact Number28Email*Reference #2 email29Reference #3*First and Last Name30Phone*Contact Number31Email*Reference #3 email32HRCI Status33CEU Approved?*Is your presentation CEU approved?YesNo34Learning Objective #1*50 words max35Learning Objective #2*50 words max36Learning Objective #3*50 words max37Important Information38• n order to ensure the Worksite Wellness Summit remains an environment that promotes education and networking opportunities between employers, we maintain a solicitation free environment, with the exception of sponsors who are hosting a booth. If you are selected as a speaker you may not directly promote your organization or your services during your presentation.
• The American Heart Association requests that all presentations comply with the following HRCI credit requirements.
• Presenters and speakers must agree to use Power Point (no exceptions) as well as the American Heart Association Power Point slide template; this will be provided to selected speakers.
• The American Heart Association requests that you sign an agreement to release your presentation materials for distribution to attendees.39Submit40All RFPs are due by 5/1/15. We will review the submissions and will get back to you with any questions and follow up by 5/15/15.
* Please submit one RFP per topic you are interested or able to speak to.*
Thank you for submitting your presenter profile to the American Heart Association’s 2015 Worksite Wellness Summit.41Questions?
Click to email: Jana Barnes42If you experience any problems submitting your application, it may be a browser issue when using older versions of Internet Explorer. If possible, try using Chrome, Safari or Firefox.43powered by FormCraft form builder