SPEAKER INTAKE FORM FOR
THE EYE HEALTH SUMMIT™
Your information for communication between us:
Your information to be featured at the summit, website and all promotional materials:
About Your Free Gift
Your 'Free Gift' is your lead magnet to collect emails and grow your list. This can be a download or another digital resources. Please provide the name and link below.
* If you don't have your lead magnet ready yet, skip this section and send it to us before March 1st.
Email List
Your social media presence
Please list your TOP social media account below (fill in at least 2)
Promotion
- All speakers agree to send at least 1 dedicated email to invite their audience to the summit during the promotional period between April 7 and 27, 2025. We also encourage sending a 2nd email as a mention (such as a e-newsletter blurb), or resend to unopened.
Questions or Comments?
SUMMIT SPEAKER AGREEMENT
This Speaker Agreement is made on the date listed below by and between The Speaker undersigned below and Rudrani Banik, M.D., PLLC.
1. I agree participate in the Eye Health Summit™ and to have my interview recorded, edited or otherwise altered as needed.
2. I hereby grant the Summit Host the right to use my interview recording, name, voice, image, likeness, in whole or in part, in any publicity, promotional, or other derivative materials based on them, in perpetuity.
3. I acknowledge that no monetary compensation is provided in exchange.
4. I reserve the right to request a copy of my interview recording and I am free to re-purpose and re-use my interview recording indefinitely and without compensation to the Summit Host, provided I identify the Host as the interviewer.
5. I understand that this is a cross-promotional partnership and I agree to promote the event during the promotional period specified.
6. I agree to indemnify and hold harmless the Host from and against all claims, losses, expenses and liabilities of every kind including attorney’s fees arising out of the inaccuracy or breach of any provision of this Agreement.
7. I expressly release The Eye Health Summit™ Host from any and all claims arising out of the use of the recording material.
By signing electronically, I agree that my digital signature is legally binding and serves as my consent to the terms outlined in this agreement, equivalent to signing in person.
© 2024 Rudrani Banik, M.D., PLLC
950 Fifth Avenue, NY, NY 10075