*To Complete the Webinar Proposal Form Electronically, Use the Tab Ley to Move to the Required

APC Professional Education Webinar Proposal10/17 /

*To complete the Webinar Proposal form electronically, use the tab ley to move to the required fields*

Webinar Title(title is subject to final editing)
Name:
Presenter(presenter will be the main contact unless specified otherwise)
Name:
Presentation Details

1. Topic (please click on box): Please Select OneAdvocacyAlternative TherapiesAssessmentCrisisDisasterDiversityDocumentationEthicsOne-Person DepartmentsPartnershipsPatient SatisfactionResearchSelf CareStaff CareTechnologyVolunteers

1. Who Should Attend? (Target Audience):

1. Our membership is religiously and culturally diverse. Will this presentation reflect aspects of more than one culture and/or religion?Yes No

If no, will your presentation be respectful of other religious and cultural traditions? Or is it intended to educate participants on a particular religion/culture? Please explain:

1. Level(please click on box): Please Select OneBeginnerIntermediateAdvanced

The APC categorizes webinars on three levels: Beginner, Intermediate, and Advanced. Use the definitions below to categorize your webinar appropriately.
Beginner: Basic information on the topic for those with little background in the area.
Intermediate: Basic plus additional information on the topic for those with some background in the area
Advanced: Specialized information on the topic for those with extensive experience and/or knowledge in the area.
Educational Objectives and Description
Educational Objectives and description will appear in promotional materials and are subject to final editing.
Educational Objectives: Limit 3 goals.
As a result of this educational opportunity, participants will be able to:
Description – Limit 100 words. Educational opportunity description should not repeat above objectives
The completed webinar proposal form may be e-mailed to .
Webinar Requirements
The information below MUST be completed. Incomplete fields will disqualify the webinar proposal form
Please note: Because the webinar slides, audio and materials will be presented to a live audience as well as recorded, you must present original material or obtain the author/copyright holder’s permission.
Please Initial below
/ I agree to obtain any necessary copyright permissions for my presentation.
Presenter
(Attach a short bio and a resume/curriculum vitae including professional presentations and published works.)
Name (as it should appear in print):
Highest Degree and Credentials: / Certified by:
Place of Work: / Title:
Mailing Address:
City: / State: / Zip Code:
Phone: / E-mail:
Religious Affiliation (if any):
Member of: APC™ ACPE CASC/ACSS NACC NAJC Other:
(check all that apply)
Your experience with the webinar topic (Limit 50 words):
The completed webinar proposal form may be e-mailed to .
Additional Presenters
(Attach a short bio and a resume/curriculum vitae including professional presentations and published works.)
Co-Presenter – 1
Name (as it should appear in print):
Highest Degree and Credentials: / Certified by:
Place of Work: / Title:
City: / State:
Phone: / E-mail:
Religious Affiliation (if any):
Member of: APC™ ACPE CASC/ACSS NACC NAJC Other:
(check all that apply)
Your experience with the webinar topic (Limit 50 words):
Co-Presenter - 2
Name (as it should appear in print):
Highest Degree and Credentials: / Certified by:
Place of Work: / Title:
City: / State:
Phone: / E-mail:
Religious Affiliation (if any):
Member of: APC™ ACPE CASC/ACSS NACC NAJC Other:
(check all that apply)
Your experience with the webinar topic (Limit 50 words):
The completed webinar proposal form may be e-mailed to .