Speaker Session Form: Piedmont Region Virginia Council of Nurse Practitioners Virginia Council of Nurse Practitioners Piedmont Region will execute the contract after the speaker has signed this agreement Please submit this form no later than: OCTOBER 31, 2026Speaker Information:Name(Required) First Last Credentials Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Website Session InformationPresentation Title(Required)Presentation Length(Required)Pharmacology Hours (if applicable)Educational sessions are expected to include pharmacology content as applicable. Pharmacology content may include, but is not limited to, pharmacology, pharmacokinetics, mechanisms of action,monitoring techniques, and potential side effects and their management and contra indications. Pharmacology credit is calculated based on the amount of time spent on pharmacology content and must be denotedas such on the presentation outline. If you have any pharmacology content, pharmacology must be a minimum of 0.25 CEs (15 minutes).Please provide a brief description of your session 3-5 sentences(Required)Employer(Required)Title(Required)BiographyThis biography will be used to introduce the speaker and will be used to promotional and informational literature. It should be between 75 to 150 wordsHandout Materials/PowerPoint Presentations• VCNP’s AV provider requires that all PowerPoint presentations be provided in advance to ensure quality control and must be provided to staff at least two weeks prior to the conference. Handouts will be distributed electronically.Please choose an option below Yes, I am emailing PPT/handout materials to VCNP to distribute electronically No, I will bring my own handouts No, there will be no PPT/handouts Handouts I agree to the Handout policy.Handouts for your presentation are essential. Please email us an electronic copy of your handouts with pages clearly numbered. The preferred software is Adobe PDF, Microsoft Office (Word, Excel, and PowerPoint). VCNP will duplicate your handout materials and they will be included in the conference handouts and/or provided to attendees via electronic methods. Presenter must represent to VCNP that all information used is public information and that no confidential and/or non-public information is included.Client Confidentiality(Required) I agree to the Client Confidentiality policyHandouts relating to a particular client should not be used unless client permission has been received, in writing, in advance. A copy of such permission must be provided to the VCNP staff representative for this program. Speakers using examples based on client experience agree to use caution and must ensure that no one in the audience, or elsewhere, can identify the client from the facts provided in the example. In addition, speaker handouts and presentations shall not contain libelous materials, or otherwise violate the rights of any other person or entity.Copyright Permission(Required) I agree to the Copyright Permission policyHandouts shall not contain information that may violate the United States Copyright Act. If copyright permission is needed to reproduce any of the materials included in speaker handouts, speakers are responsible for obtaining such permission. VCNP will not photocopy handouts that appear to require copyright permission without obtaining proof of such permission in advance.Commercial/Grant DisclosureThe VCNP has determined that a presenter’s significant financial interest or other relationships to manufacturers or organizations discussed in an educational presentation should not restrict scientific, clinical, or non-clinical presentations or publications. However, this would be true only if appropriate disclosures of such interest or relationships is made to the audience in advance so that they can make their own judgements as to how a presentation may or may not have been influenced by the presenter’s background. If it is necessary for a presenter to use a trade name, then those of several companies must be used. Also, should your presentation include discussion of any unlabeled/investigational use of a commercial product, you are required to disclose this to the attendees. Significant financial interest in other relationships would include those with: (1) manufacturers of any commercial products/processes, or providers of any commercial services discussed in an educational presentation, or (2) commercial supporters of the educational activity or their competitors.Will your presentation include discussion of any commercial products or services? Yes No Do you have a significant interest or other relationship with the manufacturer(s) of any of the products or provider(s) of any of the services you intend to discuss? Yes No This activity is support by a grant from the organization listed below.Please list the organization providing the grantDo you have a significant relationship with the supporters of the this activity? Yes No N/A Please list the relevant commercial supporters and describe the nature of the financial interest or relationshipsCommercial SupporterNature of Financial RelationshipOngoing Relationship? (yes/no) Add RemoveVCNP Polices for the SpeakerSELF PROMOTION(Required) I agreeThis program is educational in nature. Self-promotion and selling are not permitted.ANTITRUST(Required) I agreeVCNP complies with federal and state antitrust regulations. The information presented at this program is provided solely for the purpose of informing participants of current issues important to the practice. None of the information presented in this program is intended to encourage action on the part of participants that would be in violation of the federal or state antitrust laws.OPINIONS EXPRESSED DURING PRESENTATIONS(Required) I agreeThe opinions expressed by the speakers at this meeting may not necessarily be the position of the VCNP.LEGAL ADVICE(Required) I agreeVCNP reminds speakers and attendees that the program is not intended to provide legal advice and advises participants to obtain such advice from their own legal counsel.COPYRIGHT(Required) I agreeThe speaker gives VCNP permission to produce handouts of your presentation and/or make it available to program attendees via email. The speaker gives VCNP permission to use your name, photograph, and biography in connection with your presentation and related promotion, including in any digital recording of any type.PROGRAM CANCELLATION POLICY(Required) I agreeThough unlikely, VCNP is entitled to reschedule, change, or cancel this program in its entirety, or any program topic, for any reason, including but not limited to lack of sufficient registrants or uncontrollable events (e.g. weather). VCNP will notify the speaker of such changes immediately. In the event of cancellation, VCNP will not be obligated to provide any speaker with compensation for any reason. VCNP will make reasonable efforts to reschedule the program and/or use the speaker’s services for future programs. Speakers must immediately notify VCNP via telephone or email if they wish to cancel participation as a speaker for this program. VCNP requests that speakers who wish to cancel their participation do so within a reasonable time and recommend a comparable replacement.CONSENT TO BE RECORDED(Required) I agreeSpeaker hereby acknowledges and authorizes VCNP to make audio and video recordings of the presentation or lecture described below, by any means and in any media (the “Recordings”) and to reproduce, distribute, and or promote these Recordings either for profit or for free, and that VCNP will not compensate the Speaker for such use. Speaker understands that VCNP will credit Speaker as the author or source of the presentation. Speaker assigns any copyright in the recorded presentation to VCNP, but Speaker may publish or use the presentation itself as they see fit.RECORDED MATERIALS(Required) I agreeI agree that VCNP will own the Recordings, all copyrights, and other associated rights in connection with the presentation. VCNP will have the irrevocable, worldwide right to make, copy, edit, publish, distribute, play, show, display, and otherwise use and make available the Recordings and any works that may be derived from the Recordings, by any means and in any media, and to authorize others to do the same. The rights set out in the before mentioned sentence shall also apply to any handouts or material that I have provided in connection with my presentation.ROYALTIES(Required) I agreeI understand and agree that I will not receive any royalties in connection with the rights I have granted to VCNP in this document or the use and dissemination of the Recordings.Speaker agrees to this Speaker Agreement by signing below:(Required)Name(Required) First Last Date(Required) MM slash DD slash YYYY
