PEPP Speaker Request Form

Download Speaker Request Form in MSWord

Or copy and paste the following into the body of an email and send to  Lori@RSNhope.org

Contact Person
Organization/Company
Address
City State Zip
Phone
Cell Phone
Fax
E-Mail


Date of Event:
Approximate time of speaking engagement (if known):
Estimated Attendance:
Name of Meeting:
What organization is hosting the meeting?
Equipment: Can you provide an LCD projector?                        Can you provide PA if needed?
Meeting Location (please supply as much information available at this time as you know, i.e., hotel, convention center, etc.):
City
State
Zip

Please check presentations you are interested in learning about. For more information about the presentations, click here.

For Patients
__Your Achy Breaky Heart: What You Need to Know About Secondary Hyperparathyroidism
__Kidney Survivor: Lessons Learned from Experience
__Taking Charge and Adding Life to Your Years
__Make Yourself a Perfect 10!

For Professionals
__Promoting Patient Participation in the Dialysis Setting
__Empowering Patients to be Their Own Advocate
__Kidney Survivor: Lessons Learned from Experience

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