Charter Oak Conference Speaker Confirmation | Connecticut Academy of PAs

Please assist us with some administrative details for your presentation. We appreciate your assistance with completing this required information.

Charter Oak Conference Speaker Confirmation Form

Name - Please give your full name and credentials as they should appear in conference materials(Required)

First Last Credentials

Exact title of your presentation(Required)

For our marketing, mobile app and social media purposes, please give us a brief summary of your presentation that is separate from your learning objectives.(Required)

Honorarium Selection: Please choose one of the options below. Please note: Speakers provided by AAPA or another pre-accredited educational organization do not need to complete this, as payment is made directly by the contracting entity.(Required)

Honorarium $200

Hotel Reservation - Saturday, March 22

Hotel Resevation - Sunday, March 23

Hotel Reservation - Monday, March 24

Please donate my honorarium to CTPAF in support of student scholarships

Audio/Visual: To help us stay on schedule, we ask that you use our laptop, which will have your presentation preloaded. ConnAPA will have an A/V technician at all times during the conference to assist you if needed. If you have additional needs, requests, or specific instructions, please let us know. Also, please indicate if your presentation includes video content or requires audience polling through our mobile app.

ConnAPA will make your slides available as a PDF to all registered attendees through our mobile app. Do you authorize us to share your slides as a reference for attendees?

Yes

Faculty Disclosure - Please upload your faculty disclosure form that was included in your welcome email.(Required)

Max. file size: 200 MB.

Faculty Disclosure #2 - Second speaker/panelist

Max. file size: 200 MB.

If you didn’t include a headshot with your initial submission, please upload a headshot or high-quality photo for our program.

Accepted file types: jpg, jpeg, png, gif.