Speaker Info Speaker InformationEvent/Series Title(Required)Primary Sponsor of this activityLouisiana AAPWillis Knighton Health SystemLouisiana Healthcare ConnectionsArkansas AAPDHHLouisiana Dermatological SocietyMississippi AAPOtherName/ Credential(Required) First Last Credential Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Academic Information Professional Academic Title Academic Department Academic Affiliation Academic Information cont'd. City Zip Clinical Information Professional Clinical Title Clinical Department Clinical Affiliation Clinical Information cont'd. City Zip Phone(Required)Email(Required) Assistant Information (If Relevant) Name Phone number Email address Please share a brief 2-4 sentence bio(Required)Please include your current role(s) and a summary of relevant experience to this activity. CV(Required) Drop files here or Select files Accepted file types: pdf, Max. file size: 50 MB. Please upload a current CVPicture Drop files here or Select files Accepted file types: jpg, png, Max. file size: 50 MB. Please upload a current photo Δ
