NSNA CEO Appearance and Participation Request

NSNA CEO Appearance and Participation Request

Please complete this form to submit a formal request for participation by the NSNA Chief Executive Officer (CEO) in an upcoming event or program. Requests for in-person or live virtual appearances must be submitted at least 90 days before the event. Submission of this form does not guarantee availability or acceptance.
Event:
Date of Event:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Time of Event:
Start to Finish (ex: 6pm - 8pm)
Event Venue
Event Venue Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Event Format:
Event Website, if applicable
Type of Event:
Other Event Types (Please specify here):
Type of Appearance Requested:
Requested Length of CEO Participation:
Please describe the requested role of the NSNA CEO, including the proposed topic, theme, or purpose of the appearance.
Event Description and Audience:
Has the NSNA CEO’s name, title, photograph, or anticipated participation already been included in any promotional materials?
The NSNA CEO’s participation may not be announced or promoted until written confirmation has been provided by NSNA.
For in-person appearances, which expenses will the requesting organization cover? Please select all that apply:
Will NSNA be expected to incur any costs associated with this appearance?
If yes, please explain.
Is an honorarium being offered?
If yes, please provide the amount:
All Honorariums will be donated to the Foundation of the National Student Nurses' Association, Inc. (FNSNA).
Organization Type
Company:
Contact Name:

First NameLast Name
Contact Number:
Please enter a valid phone number.Format: (000) 000-0000.
Contact Email:
example@example.com
Requested Materials and Deadlines:
Upload Supporting Event Materials:

Please upload any available event flyer, agenda, program, sponsorship materials, or other information that will assist NSNA in reviewing the request.
Cancelof
By submitting this form, I acknowledge the following statement:

I understand that submitting this request does not constitute confirmation of the NSNA CEO’s participation. Participation is subject to availability, travel requirements, organizational priorities, and final written approval from NSNA. I further understand that the NSNA CEO’s name, title, photograph, or participation may not be used in promotional materials until written confirmation is received from NSNA.
Should be Empty: