Call For Presentations form

PERSONAL INFORMATION
Name:
Credentials:
Organization/Employer:
Address:
City:
State:
ZIP:
Phone:
Fax:
E-Mail:

Present Position:
Description of Current Responsibilites:
Pertinent Qualifying Experience:

EDUCATION (Most recent or pertinent to your presentation(s))
Institution:
Degree:
Major:
Year Graduated:

SESSION TITLE
Click here to choose a topic
Session Topic Code:
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)	Mentally Retarded/Developmentally Disabled- (MRDD)
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 9, 10 or 11, 2008, 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 2008. Notification of your status will be provided by that time. I am available:

Tuesday morning, Sept. 9	Wednesday morning, Sept. 10	Thursday morning, Sept. 11
Tuesday afternoon, Sept. 9	Wednesday afternoon, Sept. 10	Thursday afternoon, Sept. 11

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 Friday, February 1, 2008.

Print a copy for my records