Speaker Application

Thank you for expressing an interest in speaking at a ChiroCongress event! Please please complete this form and a team member will be in touch when they start the selection process.

Sponsored speakers will receive priority consideration.

Speaker Name Speaker Name First Last
Are you a Chiropractor?

Are you a Chiropractor? Yes No
Are you a member of a state chiropractic association?

Are you a member of a state chiropractic association? Yes No
Name of the state chiropractic association you are a member of.
Business Name (optional)
Speaker's Mailing Address Speaker's Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Speaker's Cell Phone Speaker's Cell Phone - ### - ### ####
Speaker's Email
Speaker's Web Site (optional)
Speaker Coordinator Name (optional) Speaker Coordinator Name (optional) First Last
Speaker Coordinator Phone (optional) Speaker Coordinator Phone (optional) - ### - ### ####
Speaker Coordinator Email (optional)
We have several opportunities for participating as a speaker. Please check all opportunities you are interested in participating in. (Note: We do not guarantee these positions are available, or that you will be selected for the opportunity listed. This is strictly to better understand your level of interest in each opportunity).

We have several opportunities for participating as a speaker. Please check all opportunities you are interested in participating in. (Note: We do not guarantee these positions are available, or that you will be selected for the opportunity listed. This is strictly to better understand your level of interest in each opportunity). Featured (Max 45 minutes - 1 hour) Education/Learning Focus for Association Leaders (Max 45 minutes - 1 hour) Motivation for Association Leaders (Max 45 minutes - 1 hour) Break Out Sessions - Hot Topics for Association Leaders (Max 45 minutes - 1 hour) In-person Convention Speaker Showcase- Silver Sponsorship Required (Max 15 minute) Virtual Speaker Catalog - Prices Vary - SUBMIT VIDEO PRESENTATION LINK BELOW FOR REVIEW (Max 1 hour)
Virtual Speaker Catalog Video Presentation Link
Speaker Bio (150 words or less)
Maximum of 150 words allowed. Currently Entered: 0 words.
Digital and Social Media URLs (optional)
YouTube URL: LinkedIn URL: Facebook URL: Instagram URL: Other URLS:
Summarize why you are interested in speaking to our members:
Describe what you might present on, and how it is relevant to our Association Leadership (Executive Directors, Board of Directors, etc.).
Did someone recommend you to ChiroCongress? If yes, please provide their name(s) below. (Optional)
SPEAKER COSTS AND SPONSORSHIP DETAILS
If you have a speaker sponsor, please provide their information here. (Optional)
If you have a sponsor, please describe what costs they cover (honorarium and how much, travel, food, etc.) (Optional)
If you do not have a sponsor, do you require an honorarium or other reimbursement? If "Yes", please describe below:
UPLOAD FILES
Head Shot Image (JPG or PNG preferred)

Attach Files
Other documents (Content overview, resume, speaker promo flyer, etc.) Up to 5 documents can be uploaded at one time. PDFs, Word Docs or image files can be uploaded.

Attach Files

Speaker Application

Speaker Application

SPEAKER COSTS AND SPONSORSHIP DETAILS

UPLOAD FILES