CEO Scheduling Request Form | Healthcare Businesswomen’s Association

Requestor Contact Info

Name

Organization

Component / Chapter Name (If applicable)

Is an organization/company hosting this event? If so, please specify.

Organization website address

Event Title (HBA Central approval required)

Event Purpose / Description

What HBA Stategic Pillar does this event align with?

Accelerate Careers

Accelerate Systemic Change

Accelerate Connections

Accelerate Scale & Impact

Event date

Event Start Time / Duration

Estimated number of attendees

Event Location

Preferred Format: Check all that apply below

Virtual

In-Person

Pre-Recorded Welcome Message

Type of HBA Participation Requested

Main Speaker

Panelist

If HBA's CEO is unavailable, are you open to another HBA leader/influencer?

Yes

On-Site Point of Contact (Name. Email and Phone Number)

Name

Phone

Will the event be recorded or live-streamed?

Yes

On-Site Photographer / Videographer?

Yes

Is this event sponsored?

Yes

What can the HBA contribute to make this event a success?

Individuals to recognize in presentation (Name/Organization/Title)

Please upload any relevant files (event program, w9, expense form, etc.)

One file only.
100 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

I acknowledge that travel costs are the responsibility of the hosting and/or sponsoring company unless the HBA representative is already scheduled to be onsite for another HBA-related purpose (e.g., annual conference, WODI, board meeting, etc.).

I understand submission does not guarantee a specific speaker or approval.

I confirm all information is accurate and complete to the best of my knowledge.

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