Webinar Speaker Information
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Please complete the following information. You will need to have a photo, bio and objectives ready before you can submit the form.

Thank you for agreeing to present a UCAOA Webinar. As a speaker for the Urgent Care Association of America, you must agree to the following guidelines:

• I understand that all requested materials (5 Objectives, Power Point, Bio, Picture and 5 CME Questions with answers highlighted) must be received by UCAOA ON or BEFORE the dates indicated in your confirmaton email.

• Once my slides are approved no changes will be allowed unless UCAOA specifically requests adjustments to the presentation.

I agree and acknowledge I have read the Faculty Guidelines and above information. I understand that by not following UCAOA’s guidelines listed above I am compromising the attendee experience and making it difficult for UCAOA to partner with me to create an excellent presentation. I agree that I will uphold my commitment to UCAOA as described above and in the Faculty Guidelines.

Disclosure Form

It is the policy of The Urgent Care Association of America (UCAOA) to ensure balance, independence, objectivity, and scientific rigor in all its educational activities. All program planners and faculty participating in a UCAOA sponsored educational activity must disclose to the activity audience any real or apparent conflict(s) of interest that may have a bearing on the activity. A conflict of interest may exist when individuals have both a relevant financial relationship with a commercial interest and the opportunity toaffect the content and delivery of the activity. (Relevant financial relationships can include such things as grants or research support, employee, consultant, major stock holder, member of speakers’ bureau, etc. within the last 12 months).The intent of this policy is to identify potential conflicts of interest, facilitate resolution according to protocols, and ensure that disclosure is provided to participants prior to the beginning of the activity so that learners may formulate their own judgments as to the objectivity of the presentation.

I, and any members of my immediate family, have (or have had within the last 12 months) the following relevant financialinterest in a product or device, or financial interest/arrangement or affiliation with commercial interests providing financial assistance or grants in support of this educational activity; or with any commercial interest with a financial interest in the subject matter of this activity as indicated below:

A Commercial Interest is any entity producing, marketing, re‐selling, or distributing health care good or services consumed by, or used on patients, does not include providers of direct clinical services, e.g. physician office.

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