PDT Speaker and Moderator Registration

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PDT Speaker & Moderator Registration Form

Speaker /Moderator Information:

I'm Presenting As:(Required)

Speaker

Moderator

Both

Name(Required)

Prefix First Last

Informal Name For Badge:

Job Title

Company / Agency:

Email(Required)

This email address will be used for confirmations, updates, and badge pick-up instructions. Exhibitors and sponsors are permitted a one-time use of attendee email addresses for promotional purposes unless you check the consent box. We will NOT sell your email address.

Alternate Email Address (Optional)

Provide a backup email in case your primary email is unavailable, so you don’t miss any event updates or confirmations. We will NOT sell your email address.

Consent:

Check here if you do not want your email address sent to exhibitors

Phone

Upload Bio & Headshot

Please include a short bio (max 1500 characters including spaces and a headshot in .jpg or .png

Drop files here or

Max. file size: 10 MB.

Session Details:

Session ID(s):

Session Title(s):(Required)

Session Date(s):

Session Time(s):

Speaker & Moderator Registration Options:

Speaker

The entire training includes all education sessions, social events, Solutions Hall, and the ability to earn up to 20 CPEs

My session only: Free

Entire day of my session: $350

The entire training $700 ($950-$1250 regular)

Moderator

If you are planning to attend the full training (3rd option), please visit PDT registration page for more details

My session(s) only: Free

Complimentary included in my sponsor package

I’m registering to attend the full training

Payment Information:

Payment Method(Required)

Please select your preferred payment method. Once submitted, AGA will contact you to complete the payment securely.

Credit Card

PO/SF-182/Check

PO/SF-182/Check #(Required)

File(Required)

Please include a copy of the PO/SF-182 or check to validate your registration

Max. file size: 10 MB.