1 Speaker Form 2 Financial Disclosure 3 List of Disclosures 4 Sign Off Speaker FormThank you for agreeing to speak at the 44th Annual L. Joseph Butterfield Perinatal Conference, to be held on September 12, 2023. Please complete the following form. Name (First and Last) * Email address * Cell Phone * Title of Presentation(s) * List one objective per presentation for brochure * SPEAKER LISTING FOR BROCHURE (NAME, CREDENTIALS, ACADEMIC TITLE, EMPLOYER, CLINICAL TITLE, EMPLOYER) ExamplesKay Kinzie, MSN, RN, FNP-BCClinical ManagerImmunodeficiency ProgramChildren’s Hospital ColoradoAdam Rosenberg, MDProfessor of PediatricsUniversity of Colorado School of MedicineAttending NeonatologistNeonatal ICU and Special Care ClinicChildren’s Hospital Colorado Provide your speaker listing below * Speaker bio - create a brief bio to be used as your introduction * Will you present in-person or virtually * In-person Virtually Are polling questions in your presentation * No Yes N/A Leave this field blank