Please fill out form to join the KidneySpeak-er list. The
information is for RSN Speaker identification purposes only. Once
your application is approved, your name and city will be shared with
outside parties requesting speakers.
Personal Information: |
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First Name: |
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Last Name: |
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Address: |
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City: |
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State: |
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Zip: |
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E-mail Address: |
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Phone Number: |
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Cell Phone Number: |
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Work Phone Number: |
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Occupation: |
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Educational Background: |
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What language(s) are you fluent in? |
English
Spanish
Other,
please explain:
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Experience with Chronic Kidney Disease (CKD): |
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Year Diagnosed with CKD: |
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Cause of CKD: |
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Current Treatment Modality:
(check one) |
Transplant
CAPD
CCPD
In-Center
Hemodialysis
Home
Hemodialysis, please explain type:
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Past
Treatment Modalities:
(check all that apply) |
Transplant
CAPD
CCPD
In-Center
Hemodialysis
Home
Hemodialysis, please explain type:
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Do you keep up on the latest information regarding the following:
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CKD
Transplant
Dialysis |
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Please provide a brief overview of your personal experience with
chronic kidney disease: |
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| What aspect(s) of
the disease affects your quality of life the most? |
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| Do you think
patients on dialysis or who have a transplant should be active in
making decisions about their own care? |
Yes
No
Please explain:
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Speaking Experience: |
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1) What interests you about becoming an RSN speaker? |
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2) Have you ever spoken to any individuals or groups to increase
their knowledge about dialysis, transplant or chronic kidney
disease? |
Yes
No
Please explain:
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3) Have you ever spoken in public about other topics? |
Yes
No
Please explain:
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4) What is the largest number of people you have spoken to? |
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5) Are you a member of Toastmasters? |
Yes
No |
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If yes, what is your speech level? |
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6) Have you ever had any other speaker training?
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Yes
No
Please explain:
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7) In your opinion, what makes a good speaker?
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8) Is there something about your speaking that you would like to
improve?
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Yes
No
Please explain:
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9) If applicable, please list three of the more recent presentations
that you have given.
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Title:
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Audience:
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Title:
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Audience:
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Title:
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Audience:
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| 10) Have you ever used a PowerPoint presentation?
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Yes
No
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11) Do you have PowerPoint on your computer?
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Yes
No |
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Other: |
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1) How far are you able and willing to travel? (in miles)
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2) Do you have any travel limitations?
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Yes
No
If yes, please explain:
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3) Please type any additional comments or information here:
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Application Requirements:
Please provide the contact information of two renal healthcare
professionals who would provide you with a personal reference: |
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First Reference |
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| Name: |
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Title: |
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Phone: |
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Second Reference |
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| Name: |
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Title: |
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Phone: |
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In order to stay up to date with the latest in policy changes that
affect people with kidney disease, all RSN speakers are required to
join weKAN. |
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Yes, I
agree to join
weKAN |
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Include with your application:
At least two letters of recommendation
(Ask your doctor, social worker, local NKF, ESRD Network,
Toastmaster president, or other source.)
A 3–5 minute recording (audio or
digital) of yourself. (Digital is preferred, but audio is
acceptable). Talk about your interests, hopes, or aspirations,
and why you want to speak for RSN. If you are unable to provide
a recording, please call and tell us your story at the RSN’s
KidneyTalk Voice Mail number, at 866-379-4673; be sure to leave
your name. We can download this file and hear a sample of your
speaking voice.
A recent photo of yourself.
Optional) An audio or video clip of a
past presentation that you’ve given. Include the date, location,
name of event, and name of presentation.
If you have further questions, contact Renal
Support Network at:
info@RSNhope.org
866-903-1728
818-244-9540 fax
www.RSNhope.org
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