Images of You : Program Proposal Form

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Program Proposal Form

* Required Fields

1. Coordinating Presenter Information

* Name:

* Position/Title:

* Email:

* Phone:

2. Other Presenters

Presenter #2 Name:

Presenter #2 Title:

Presenter #3 Name:

Presenter #3 Title:

Presenter #4 Name:

Presenter #4 Title:

* Do you plan to attend the workshop in its entirety?

YesNo

3. Program Information

* Program Title:

Please insert a 500-word maximum description of your program. Your program description should include three to five learning objectives and how the objectives will be met during your presentation.

* Program Description:

Please insert an 80-100-word abstract of your presentation that will appear in the conference packet if your proposal is selected.

* Program Abstract:

* Ideal Attendance:

4. Equipment Needs

Please select any audio/visual equipment needed for your program:

TV/VCR and monitor
Flip Charts with markers
LCD Projector
Screen for personal LCD projector
Overhead Projector & Screen

5. Program Time

During which session are you able to present? Please check all boxes that apply.

Workshop 1: 2:00 - 2:45
Workshop 2: 3:00 - 3:45
Workshop 3: 4:00 - 4:45

Would you like to present more than once during the day?

Yes No

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Program Proposal Form