CAIRIBU Event Speaker Form CAIRIBU Event Speaker Form URLThis field is for validation purposes and should be left unchanged.Name(Required) First Last Email(Required) Enter Email Confirm Email Institution(Required)Event Series(Required) CAIRIBU ARCTICS Community Forums CAIRIBU Connections CAIRIBU Graduate Student Seminar CAIRIBU K12 Scholar Seminar CAIRIBU Research Interest Group (BPH, Uro-Aging, Urobiome, or Uro-Immunology) Unknown Other Date of Event(Required)Title of Presentation(Required)To be used for promotional purposes. Can be a working title.Headshot(Required)To be used for promotional purposes.Max. file size: 10 MB. Professional BioTo inform how the moderator will introduce you.Mailing Address(Required)The CAIRIBU Interactions Core will send you a small thank you gift for speaking. Please provide an address where you may receive small packages. 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Recordings will capture any or all of the following: PowerPoint or other presentation materials shared by presenters and event organizers; video of presenters and event participants; audio of presenters and event participants (e.g., during discussion and Q&A), and still photographs and/or screenshots of presenters and participants. Please consider providing your consent to disseminate any recording(s) of you during the specified event. This covers all information and materials you shared during your presentation(s). Your consent covers the dissemination of your presentation(s) in all formats and media for an unlimited period of time. This may include posting on the CAIRIBU YouTube channel, on the CAIRIBU website, on the CAIRIBU Twitter account, and/or on the websites or social media of individual CAIRIBU Centers and Programs. Full credit to you will be provided in any dissemination; you will be identified by name and the affiliation under whose auspices you delivered the presentation. You may request the exclusion of certain slides or images from broad dissemination. Your consent herein in no way restricts the publication or dissemination by you or anyone authorized by you of this material in any form. I agree with the terms and conditions listed.Do you request the exclusion of certain slides or images from broad dissemination?(Required) Yes No Please specify your request to exclude certain slides or images from broad dissemination.Presenter's Initials(Required)
