Speaker

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Speaker Information

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Organization

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Email Address(Required)

Mailing Address(Required)

Social Media Handles

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Speaker Bio(Required)

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Session Details

Session Title

Objectives

Outline of the Presentation(Required)

Duration

30 min

45 min

60 min

Other

Target Audience

Healthcare Admins

Leaders

Other

How Will this topic be beneficial to leaders?

General A/V Needs

Projector

Microphone

Laptop Hookup

Speaker Responsibilities

The speaker agrees to

Present the confirmed session during the scheduled time

Provide presentation slides and materials by January 10, 2026.

Promote their participation on social media or within their network (optional but encouraged).

Participate in Q&A, panels, or pre/post conference engagement (if applicable).

Grant permission for the session to be recorded and/or photographed (unless otherwise agreed).

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First & Last Name(Required)

Title/Organization(Required)

Email(Required)

Phone(Required)

NAB# (for LTC or AL Administrators only)

Breakout Workshop Selection (Day 2: 10:30 AM – 12:30 PM)

Please select one workshop below:(Required)

Transforming Dementia Care: Leadership Tools for Managers in Healthcare and Beyond

Learn practical ways to support staff, reduce burnout, and strengthen person-centered dementia care.

The Genius of Teamwork: Unlocking the Six Working Geniuses in Leadership

Discover how to harness each person’s natural genius to build balanced, high-performing teams.

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Special Requests or Dietary Restrictions

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Name(Required)

Company Name(Required)

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Phone(Required)

Current Job Title and/or Qualifications(Required)

Topic of Presentation(Required)

URL

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Sponsor Information

Organization/Business Name(Required)

Contact Person(Required)

Email Address(Required)

Phone(Required)

Mailing Address

Street Address City State / Province / Region ZIP / Postal Code

Sponsorship Options Tier 1(Required)

None

Torchbearer Sponsor – $2,500 (Title Sponsor)

Visionary Flame Sponsor – $1,500

Beacon Blaze Sponsor – $750

Catalyst Spark Sponsor – $500

Steady Ember Sponsor – $250

Lead on Fire Friend – $100

Select Qty

Sponsorship Options Tier 2(Required)

None

Breakfast Sponsor - $500

Break Sponsor (AM or PM) - $300

Speaker Session Sponsor - $750

Quantity

Vendor Opportunities(Required)

None

Yellow Spark Vendor – $150

Payment Information

Payment Method(Required)

Check

Credit Card

Invoice Needed

Yes

Coupon

Total

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Additional Notes or Special Recognition Requests

Lead on Fire 2027 CEU Leadership Conference

Speaker Information

Session Details

Speaker Responsibilities