BECOME A MEMBER
Dakota Diabetes Coalition Webinar Speaker Form
Please complete this form at your earliest convenience
Thank you for agreeing to be a speaker, and for your contribution to addressing diabetes in North Dakota
Please list degree(s), institution(s) attended (please include City and State), and graduation year(s).
Please provide a short bio for your introduction.
Include training and employer/employment as it relates to your topic, as well as how you would like to be introduced as a speaker.
Upload a Resume/CV
Drop files here or
Accepted file types: pdf, doc, docx.
Title of Presentation
Date of Presentation
Date Format: MM slash DD slash YYYY
Please provide a minimum of three learning objectives.
Post Webinar Quiz Questions
Please provide a minimum of five post webinar questions and answers.
1. Post webinar quiz question?
a. First answer
b. Second answer
c. Third answer
d. fourth answer - Correct
2. Post webinar quiz true or false statement.
a. True - Correct
Teaching Strategies to be used
Please check all that apply
PowerPoint Presentation (Please provide the document 3 weeks prior to the presentation date)
For "Other" please provide detail
Please provide a synopsis of the presentation and/or attach any reference materials below
Presentation or Reference Materials
Drop files here or
Accepted file types: pdf, pptx, jpg, png, docx, xlsx.
Conflict of Interest Disclosure
The section is required. While an interest of affiliation with a corporate organization does not prevent you from making a presentation, the relationship must be made known to attendees.
I hereby certify that, to he best of my knowledge, no aspect of my current personal or professional circumstance places me in the position of having a conflict of interest with this presentation. I hereby certify that, to the best of my knowledge, neither I (including any member of my immediate family) have (has) received something of value from a commercial party related directly or indirectly to the subject of this presentation.
The foregoing statements are true without exception.
The foregoing statements are true expect as reported in detail below.
If you have relationships to repot, list the type(s) of relationship(s) and list organization below the category.
Other Financial Interests
Digital Signature (Please enter your full name)
By selecting the "I Accept" checkbox, you are signing this agreement electronically.
Username or Email Address
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