Speaker Agreement Complete and submit this form by 5pm ET on March 15, 2023. If we don't receive your submission by that time, we will need to give your spot to another presentation. Step 1 of 5 20% Presentation detailsHiddenSession ID HiddenSession Type Impact - In Person Impact - Virtual Express Flash Presentation Title(Required) We use this to connect you with the original submitted proposal.Are you the primary presenter or a co-presenter?(Required) Primary presenter (lead) Co-presenter Personal detailsName(Required) First Last Display Name(Required) Your name as you'd like it displayed in the printed and online programs, including any credentials (MBA, PhD, MD, etc.)Title / Role(Required) Organization / School(Required) Email(Required) PhoneBio(Required)This will be displayed in the online program.Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Travel stipendWould you like to have NAMI pay for your travel expenses (round trip airplane ticket & 1 night at the NAMICon hotel) — or would you like to donate this to support a scholarship for an attendee living with mental illness? In either event, we'll pay for your NAMICon registration costs.Accept or donate your travel stipend?(Required) Accept. This will help me attend NAMICon in-person. Donate. Fund a scholarship to help a peer attend NAMICon. DemographicsDemographic information is optional. We use this data to ensure that we engage a diverse group of presenters.AgeUnder 18 years18-24 years25-34 years35-44 years45-54 years55-64 years65-74 years75-84 years85 years or olderI prefer not to answerRace, ethnicity or origin American Indian or Alaska Native Asian Black or African American Hispanic, Latino or Spanish origin Middle Eastern or North African Native Hawaiian or Other Pacific Islander White Another race, ethnicity or origin (please specify) Prefer not to answer Another race, ethnicity or origin Gender Agender Man or boy Non-binary, gender-fluid, or gender-non-conforming Questioning/unsure Transgender Woman or girl Another gender (please specify) Prefer not to answer Another gender Sexual orientation Asexual Bisexual Gay Heterosexual (straight) Lesbian Pansexual Queer Questioning/unsure Another sexual orientation (please specify) Prefer not to answer Another sexual orientation Military serviceNever served in the militaryOn active duty for training in the Reserves or National GuardNow on active dutyOn active duty in the past, but not now (veteran/former military)Prefer not to answer Speaker agreementSpeaker agreement(Required) I agree to the NAMICon 2023 terms and conditionsI understand that any request for a presenter's substitution (replacing one speaker with a different speaker) must be done in writing and requires prior approval from NAMI. Substitutions without NAMI's prior approval may result in cancellation of the workshop or express talk. I understand that workshops or express talks must be a true representation of the proposal that was accepted. NAMI reserves the right to cancel a workshop or express talk that is different from the originally accepted proposal. I hereby authorize the recording and offering for sale the recordings of our presentation at NAMICon 2022. This authorization is granted with the understanding that the grantee will not assert any copyright or deprive us of any other rights that we may have in the materials we present. I agree to notify NAMI immediately in the event that an emergency should prevent me from meeting my obligation as a session speaker. I understand and confirm that content will be free of commercial product or service bias and the content will reflect the session title given. I have read, understood and agreed to adhere to the NAMI’s Code of Conduct, NAMI’s Terms of Use and NAMI’s Privacy Policy.
