62nd Annual Convention – Peoria – September 10-13, 2012

Application Form

  • All proposals must be submitted by Wednesday, February 1, 2012.
  • If you are not available September 11, 12, or 13, 2012, please do not submit an application.
  • If you are available for the convention dates, please put a tentative hold on the dates.  The speaker selection process will be completed by mid-April 2012.  Notification of your status will occur by that time.

PERSONAL INFORMATION
First Name:
Last Name:

Credentials:
Organization/Employer:
Address:
City:
State:
ZIP:
Phone:
Fax:
E-Mail:
   
Present Position:
Description of Current Responsibilites:
Pertinent Qualifying Experience:

ACADEMIC HISTORY

Institution:
Degree:
Major:
Year of Graduation: (yyyy)

SESSION TITLE

Click here to choose a topic
Session Topic Track:

Session Title: 

Please create a title of your choosing; topic integrity must be maintained.

SESSION DESCRIPTION

Provide a 75-word narrative that relates the topic to trends, issues, or challenges in long-term care and explains the value of the information and identifies new/unique applications. Session length will be 90 minutes. Note: If this proposal is accepted for presentation, convention publications will include this text (subject to editing):

SESSION OBJECTIVES
List three learning objectives by completing the statement, "At the conclusion of this session, the participant should be able to:"  Note: If this proposal is accepted for presentation, convention publications will include the following text (subject to editing):

 
1.
2.
3.

TARGET AUDIENCE

Besides the primary educational track that the session falls under, identify any other track to which the session applies (limit to 3):

Activities (ACT) Multi-Disciplinary (MULTI)
Administrators/Owners (ADM) Nursing (NUR)
Assisted Living (AL) Personal Enhancement (PER)
Business Office/Front Office (BIZ) Developmentally Disabled (DD)
Certified Nursing Assistants (CNA) Social Services (SS)
Dietary (DIET) Department Supervisors (SUP)
Environmental Sciences (ENV) Therapies (THER)

CO-PRESENTERS

I will do the presentation alone.
I will do the presentation with (List the name, credentials, organization, and contact/address information for each co-presenter):
 

SPEAKING HISTORY

Identify your experience in making presentations to groups:
  Significant Experience
  Moderate Experience
  Limited Experience

 
Identify your association with IHCA or other organizations:
  I have spoken at a previous IHCA convention..
  I will be a new speaker for IHCA.  List a recent speaking engagement and respective contact:

 
Contact Person
Contact Phone
Organization
Event
Date of Event
Title of Presentation

BIOGRAPHICAL INFORMATION

Provide a one-paragraph narrative for each person participating in the presentation (subject to editing):

IHCA MEMBERSHIP


Associate Member
Individual Member
Full Member
Non-Member

COMPENSATION

My organization will sponsor the session  therefore, IHCA will not incur any costs for me to speak.
I will need an honorarium of and IHCA will not incur any other costs for me to speak.
I will need an honorarium of and reimbursement for incidental expenses.
 
If an honorarium is required, is the fee for a single day (one or more sessions) or per session?  
DAY       SESSION        Other
   
If Other, please explain:

AVAILABILITY

If you are not available to speak in Peoria, Illinois on September 11, 12 or 13, 2012, please do not submit this application.  If you are available, please put a tentative hold on the dates.  The speaker selection process will be completed by mid-April 2012.  Notification of your status will be provided by that time.

I am available:

Tuesday morning, Sept. 11 Wednesday morning, Sept. 12 Thursday morning, Sept. 13
Tuesday afternoon, Sept. 11 Wednesday afternoon, Sept. 12 Thursday afternoon, Sept. 13
     

Proposals accepted for presentation entitle the presenter to complimentary registration to the convention and trade show.

For inclusion in the selection process, this form must be submitted by Wednesday, February 1, 2012.

Questions?  Contact Debbie Belt, IHCA Vice President Education/Clinical Services, at 217-528-6455 or 800-252-8988.

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