HCP Speaker Application | Diversity In Diabete

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Join us for our Monthly Insulin Inclusive Support Group. RSVP Now. Free to join. Packed with great information.

Health Care Provider Speaker Application

First name

Last name

Phone

Pronouns

Organization/Affiliation (If Applicable)

Social Media Handles (If Applicable)

What is Your connection to Diabetes (Check all that Apply)

I have Type One Diabetes

I have Type Two Diabetes

I have Lada/Mody Diabetes

I am a Health Care Provider

I am a caregiver for someone with diabetes

I am an advocate for the diabetes community

Other (specify)

Please provide a brief description of your proposed session

What format would you like to present in?

Workshop

Panel Discussion

Personal Story/Experience Sharing

Interactive Activity

Other (please specify)

Have you presented at a similar event before? (Yes/No)(If yes, please list any past speaking engagements)

Be advised all sessions are recorded for later viewing. Please indicate if you are comfortable with that.

Yes

Do you have any accessibility needs or accommodations?

Why do you want to speak at the POLWD Virtual Summit?

Please upload your headshot and a brief bio below. This will help us introduce you more easily in the future.

Diversity in Diabetes

Education

Care Directory

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