Speaker Form

Name *

First

Last

Email *

Please check whether you agree to speak for the 2023 Empowering Communities for a Healthy Mississippi Conference. *

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.

Call to book your hotel at (601) 936-4550 or use the link directly to book. Use code EMP for the discounted rate. Out of state/area speakers will be contacted separately to discuss travel and hotel accommodations.