“Partners in Shaping the Future”
90 Minute Workshop Proposal
Application Deadline:
Submitted No Later Than
Friday, September 15, 2017 /
*To complete the 90-Minute Proposal form electronically, use the tab ley to move to the required fields*
Workshop Title(title is subject to final editing)Name:
Presenter(presenter will be the main contact unless specified otherwise)
Name:
Presentation Details
- Topic (please click on box): Please Select OneAdvocacyAlternative TherapiesAssessmentCrisisDisasterDiversityDocumentationEthicsOne-Person DepartmentsPartnershipsPatient SatisfactionResearchSelf CareStaff CareTechnologyVolunteers
- Format(please select all that apply):
- Level(please click on box): Please Select OneBeginnerIntermediateAdvanced
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.
I am NOT available to present this workshop on the following date(s) (please click on box):
Educational Objectives and DescriptionEducational Objectives and description will appear on the conference website 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
Workshop Requirements
The information below MUST be completed. Incomplete fields will disqualify the workshop proposal form
Conference attendees will have access to an outline from each workshop presenter prior to the Conference. Workshop handouts will be posted on the APC/NACC websites prior to the start of the conference. It is the presenter’s responsibility to provide handouts at the workshop session if not posted on the website.
In order to be considered for presenting at the 2018 APC/NACC Joint Conference each statement MUST be initialed.
Initial below
/ If selected to present, I will obtain all permissions to reprint materials I have submitted for inclusion on the APC/NACC websites
/ If selected to present,
OUTLINE
I will provide a 2-page (maximum) outline in electronic format for inclusion on the APC/NACC websites SUBMITTED no later than Friday, January 12, 2018
HANDOUTS
I will provide a handout in electronic format for inclusion on the APC and NACC websites SUBMITTED no later than Friday, April 20, 2018
Presenter
(Attach a one page 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 workshop topic (Limit 50 words):
The completed workshop proposal form may be e-mailed to .
Applications must be submitted by Friday, September 15, 2017
Additional Presenters
(Attach a one page 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 workshop 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 workshop topic (Limit 50 words):
The completed workshop proposal form may be e-mailed to .
Applications must be submitted by Friday, September 15, 2017