Information for COPD Support groups  for the benefit of the COPD patient
         

        


Speaker's Information Form

Any speaker contact requests pertaining to you will be forwarded directly to you. 
It will then be up to you to establish the communication.

For your privacy, your address, phone numbers, and email address will
NOT be shown on the website, nor will they be given to anyone.

Your Name:
Mailing Address:
    City: State: Zipcode: Country:

Phone Numbers:
Email Address:
Your Website URL
(Leave Blank for None)
Area that you are will travel to speak:
International:             National:              Regional:              Local:
If Regional or Local, please specify:

Types or size of groups you would like to speak to:
Please specify:
(example- schools, Luncheon groups, small clubs, major conferences, anyone anywhere etc.)


Subject material or theme of talks/speeches (Note: If you feel that you can speak well on a number of different subjects -- i.e. quit smoking, Living with COPD , Caregiving, etc., then please list each as separate subjects):

      Subject:

      Subject:

      Subject:

      Subject:


These next two boxes are for your biographical information. 

In 50 words or less, please tell us a bit about you, your involvement with COPD, your speaking style etc (This will be used for the pop up on the speakers page)
Additional biographical information to be used if additional information is desired by some inquiring organization.

COPD or Medical websites and organizations that you are active with:


      

 

Comments:

Your feedback
is appreciated.

Thank you for your submission.
It will be reviewed and should be online
within the next 24 - 48 Hours