1 Start 2 Section 2 3 Section 3 4 Section 4 5 Section 5 6 Section 6 7 Section 7 8 Review 9 Complete Thank you for serving as a presenter for an ASTRO educational activity. You don't need to log in to complete this form, but logging in with your ASTRO credentials will allow you to save the form and return to it, if needed. Once logged in, you will see a Save Draft button at the bottom of each page. To return to the form, log in to the ASTRO Academy and paste the URL for the form, https://academy.astro.org/content/astro-educational-program-presenter-form, into your browser tab.Please contact ASTRO eLearning with any questions. PRESENTER INFORMATION Full Name * Please enter your full name including your credentials. Display Name Please enter your name as you would like it to display in activity materials and promotion, If different than full name above. Presentation Title * Email * Cell Number If you are participating in a live activity, please provide your cell number. This would only be used if ASTRO needs to reach you urgently (e.g., technology issue). Occupation * - Select -AdministratorBiologistClinical OncologistDentistDiagnostic RadiologistGraduate StudentMedical DosimetristMedical OncologistMedical PhysicistNuclear Medicine PhysicianNurseNurse PractitionerPatient AdvocatePhysician AssistantPostdoctoral FellowPulmonologistRadiation OncologistRadiation Therapist / TechnologistResident / FellowStudentSurgical OncologistUrologistVeterinarian Primary Employer * - Select -Academic / University SystemCommunity Based SystemGovernment / Public SectorIndependent Contractor / Locum TenensIndustryPrivate PracticePrivate Practice / Community Based SystemOther Primary Employer Other Affiliation * Please enter your institution/practice name as you would like it to display in activity materials and promotion. Professional Title(s) * [e.g., Associate Professor / Director of...] Pronouns * She/Her/Hers He/Him/His They/Them/Theirs Prefer Not to Say Assistant's Name Assistant's Email The information above will be used for your activity role. If you would like to make permanent changes to the information in your ASTRO profile, please visit MyASTRO. Leave this field blank
