AAPA Speaker Request Form

Submit this form to request a visit by an AAPA Board member (including the CEO) or other volunteer leader (e.g. committee chairperson). Please submit requests at least 12 weeks in advance of the desired event date to ensure time for appropriate review and planning. The form is designed to capture as much information as possible to inform the decision-making process; however, you may be contacted for additional information. A staff member will reply to your request as soon as possible.

Requests for a staff member to speak may be sent directly to the staff member. A staff directory is available on the AAPA website.

Please contact governance@aapa.org with questions or if you require assistance. Thank you.

Basic Information

Event name *

Event location and address (e.g. Big City Convention Center, 100 Main St., Anytown, ST) *

Name of organization requesting a speaker (please no acronyms) *

Primary point of contact *

Title *

Email *

Phone number *

Organization or event web address *

Presentation Information

Preferred presenter (Speaker is determined based on availability and topic). *

AAPA President

AAPA CEO

Other AAPA Board Member

Other (please specify) Other (please specify)

Preferred presentation topic *

Trends and current issues (May qualify for CME)

About AAPA/ "State of the Academy"

Overview of the PA profession (designed for the non-PA audience)

Healthcare Leadership and Managment

Other (please specify topic) Other (please specify topic)

Type of presentation *

Date of presentation * +

Do you have any flexibility if this date is unavailable? (please add brief detail) *

No

Yes Yes

Time of presentation (If flexible or currently unknown please enter "TBD") *

Total length of remarks, including any Q&A or panel discussion. (20 minutes minimum) *

Do you want to include audience Q&A? *

No

Yes (please specify how long) Yes (please specify how long)

Will you be applying for CME credit for this session? *

Yes

No

Uncertain / TBD

If the invitation relates to a session with multiple speakers (e.g. panel, membership meeting, etc.) please list the other invited speakers. *

Estimated number of session attendees. *

Type of attendees expected (please check all that apply) *

Are you inviting any AAPA staff to this event? *

No

Yes (please specify who and in what capacity) Yes (please specify who and in what capacity)

Please provide a preliminary copy of your program agenda, if available. AAPA requires that the name and position of AAPA representative(s) be listed in the final printed and online programs.

Speaker Logistics

What information does the host organization need? *

Does the speaker need to be registered for the event? *

Yes (registration fee waived)

No

If registration is required, please provide information on how to register, including any applicable registration discount codes.

Is the host organization funding the speaker's travel? *

Yes

No

Is the host organization funding the speaker's accommodations? *

Yes

No

Please provide hotel name, physical and web address of hotel. If it is the same as the event venue, please indicate "Same". *

Additional Opportunities

AAPA looks at each invitation to speak as an opportunity to fully engage with PAs, students, healthcare leaders and other stakeholders. Therefore, we encourage opportunities for AAPA speakers to engage beyond the primary speaking request. This section aims to explore what additional opportunities may be available.

Do you anticipate media coverage at this event? *

Yes

No

What opportunities are available to meet with your organization's leadership? *

We have a Board meeting scheduled in coordination with the event, and can provide time on the agenda.

We can arrange a small group meeting with a select group of Board members.

We can arrange a meeting with our President or CEO.

None

Not applicable. The primary request is for a Board presentation.

What other opportunities are you interested in exploring? *

What Did We Miss?

Other comments/questions/specific requests

Thank you for your request.