Conference 2025 Speaker Application

"*" indicates required fields

[email protected] | This is the email that will be used for conference communication.
Please enter a valid phone number.
Do you plan on your presentation containing any audio or videos?*
PA Moms will try to accommodate slots based in the order applications are submitted.
Honorarium Option*
Drop files here or
Max. file size: 512 MB.

    Disclosure Information

    Faculty Disclosure Form

    A conflict of interest may exist if a faculty member of an educational activity, or spouse or partner of that person, has financial relationships with the grantor or any commercial interest(s) that may directly impact the content of the program. A financial relationship is defined as being a shareholder, consultant, grant recipient, research participant, employee, and/or recipient of other financial or material support. The participants in this CME activity must be made aware of any such financial relationship(s). All persons who may have control over the content must fully disclose any such financial relationship. This disclosure policy is intended to protect all parties involved from potential conflicts of interest that may arise. AAPA assumes responsibility for resolving these conflicts of interest. If you have no disclosures, please only complete the required items (designated with a red asterisk) below.
    Do you intend to discuss any unapproved / investigational use of a commercial product / device?*
    I will provide a balanced view of therapeutic options and will be entirely free of promotional bias*
    Enter your name (only if you have disclosure)
    Enter your spouses name (only if relevant to a disclosure)

    Please fill out the name of commercial interest (if applicable) to the Financial Relationships below.


    MM slash DD slash YYYY

    Free Shipping on all PA Moms products!

    PA Moms Women's Medical Summit 2025 tickets are now on sale!