2026 Speaker CRCE AARC Registration – Connecticut Society for Respiratory Care

This form combines the previous Biographical Data and Vested Interest forms into one form. Note that Vested Interest information must now be provided to the AARC. Thank you for taking the time to complete this information, the CTSRC is honored to have you present at our 2026 event!

Name(Required)

First Last

Email(Required)

Employer(Required)

Job Title(Required)

Primary Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Credentials – Select as many as apply(Required)

If you have a credential not listed above, please write it here

Highest degree earned(Required)

Title of Presentation(Required)

Select your content area(Required)

2-3 Learning Objectives(Required)

Teaching Strategy(Required)

Please provide a description of your expertise/experience in relation to the topic(s) you are presenting. Please include any professional credentials:(Required)

Speaker Intro(Required)

Note: (i) This section must be completed for all individuals identified in the documentation of educational activities. (ii) Alternatively, special forms that identify a vested interest may be submitted in place of the section below. Definition: An individual involved in the planning of or presentation of an educational activity may have an interest in or affiliation with an organization but the audience must be informed of this relationship before the presentation of the activity. For this purpose, a real or apparent conflict of interest is defined as personal gain or benefit derived from involvement with any entity, product or service. Vested Interest includes but is not limited to employment, by owning stock, from inclusion in a speakers’ bureau or a relationship, personal or otherwise, with a company that could potentially benefit from the relationship.

I have an affiliation or financial relationship/interest which could be perceived as posing a potential conflict of interest with the educational program.(Required)

YES

I have a significant relationship with the commercial supporter (sponsor) of the session(s).(Required)

YES

I, or a family member or partner, have a significant financial interest or other significant relationship with one or more companies who manufacture pharmaceuticals or medical devices used to treat respiratory patients.(Required)

YES

I have discussed with planning committee member(s) and confirmed this relationship will not impact the program.(Required)

AGREE

DISAGREE

List commercial company(ies) below that may be a conflict

Do you have any conflicts to list?(Required)

YES

Consultant/Speakers' Bureau

Employee

Stockholder

Product Designer

Grant/Research Support

Large Gift(s)

Other Support (Specify)

I will:(Required)

accept the $250.00 honorarium. (A check will be given the day of the symposium.)

donate my $250.00 honorarium to the CTSRC.