Speaker Application

for the Ohio Person-Centered Care Coalition Conference

CREATING HOME THROUGH CHOICE & PURPOSE

When:March 8, 2012

Where:The Aladdin Shrine Event & Convention Center

3850 Stelzer Road, Columbus, OH 43219-3044

To apply to speak at the conference, simply complete this form and submit it one of two ways:

  1. E-mail a completed Word document to (you may also e-mail this address with any questions)
  2. Fax a completed form to 740-965-1910

Deadline for submitting an application: October 14, 2011

I.Tell us about your presentation

Title
Length of session
Target Audience (check all that apply):
Activities
Administration
Admissions/Marketing
Dietary
Direct Care
General
Social Service
Other(s)
/ Level of Sophistication (check one):
Introductory
Intermediate
Advanced
Instructional Methods (check all that apply):
Lecture
Panel Discussion
Workshop
Other

II.Learning objectives

At the end of this session, participants will… (list three)

Objective 1
Objective 2
Objective 3

III.Session description

Please include a 2 or 3 sentence summary of the session’s content. The summary must include a concise description of the content which explains the value of the information and identifies new or unique applications. This information will be used in the promotional brochure that attendees read to choose between the variety of concurrent sessions offered. You are encouraged to write it in a style that will convince attendees that your session is the one to attend and convince the committee that your session is the one to select!

IV.Other details

Below, include other information that the committee should consider when evaluating this presentation.

V.Audio/visual needs

List any audio and/or visual tools you will need for your presentation (i.e. computer, projector, microphone, etc.)

VI.Presenter information – all correspondence about this session will be with the first presenter listed.

Presenter 1 name / Presenter 2 name
Title / Title
Organization / Organization
Address / Address
City/State/Zip code / City/State/Zip code
Phone number / Phone number
Fax number / Fax number
e-mail / e-mail
Presenter 3 name / Presenter 4 name
Title / Title
Organization / Organization
Address / Address
City/State/Zip code / City/State/Zip code
Phone number / Phone number
Fax number / Fax number
e-mail / e-mail

VII.Presenter bios

A one-paragraph biography for each speaker (do not submit resumes or CV) indicating skills and professional background as it relates to the topic being presented. This may be used at the event as well as in promotions for the event, so please make it concise and relevant to the chosen topic.

Presenter 1
Presenter 2
Presenter 3
Presenter 4

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