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Personal Information
Name:
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Credentials:
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Title:
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Organization/Employer:
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Employer's Address:
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Street Address
Address Line 2
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Cell Phone:
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Email:
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Website:
Video Link (of you presenting):
Knowledge/Experience Related to Presentation:
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Your Short Biography:
*
Please provide a third person, one paragraph description of experience. This may be published for promotional materials and may be subject to editing.
Upload Your Resume:
Accepted file types: pdf, doc, docx, Max. file size: 10 MB.
Academic History
Institution:
*
Degree:
*
Major:
*
Year of Gradution:
*
Presenter Experience:
*
Significant
Moderate
Limited
Compensation:
*
AHCA will incur no cost for speaking
I will need an honorarium
Requested honorarium
Honorarium amount requested:
*
Travel Reimbursement:
*
I will not have travel costs to be reimbursed
Travel
Overnight Accommodations
(select all that apply)
I understand that if selected, I am required to submit my PowerPoint to AHCA for review one month prior to the event. AHCA reserves the right to cancel a session if the content does not match the needs of the audience.
*
I understand
I understand that if selected, I am required to submit a handout of content to AHCA one month prior to the event, even if I would not like my PowerPoint shared with attendees.
*
I understand
I understand that if selected, I am required to submit my PowerPoint to AHCA for review one month prior to the event. AHCA reserves the right to cancel a session if the content does not match the needs of the audience or the content is not educational and markets a specific brand and/or company.
*
I understand
How many sessions would you like to submit?
*
Select one
1
2
3
4
5
Session 1
Session 1 Title:
*
Target Audience:
*
General
Activities Professionals
Administrators (SNF)
Assisted Living Centers
CNA/Caregiver
Dietary Professionals
Environmental Services
Executive Directors (AL)
Nursing Processionals
Skilled Nursing Centers
Social Services
Supervisors
Therapy Professionals
Other
(select all that apply)
Target Audience - Other:
*
Description:
*
Objectives:
*
Length of the session in minutes:
*
Type of Event:
*
Annual convention breakout session
Annual convention general session
Seminar (1/2 day) / Forum (full day) presentation (dates to be determined)
Webinar (dates to be determined)
(select all that apply)
Session 2
Session 2 Title:
*
Target Audience:
*
General
Activities Professionals
Administrators (SNF)
Assisted Living Centers
CNA/Caregiver
Dietary Professionals
Environmental Services
Executive Directors (AL)
Nursing Processionals
Skilled Nursing Centers
Social Services
Supervisors
Therapy Professionals
Other
(select all that apply)
Target Audience - Other:
*
Description:
*
Objectives:
*
Length of the session in minutes:
*
Type of Event:
*
Annual convention breakout session
Annual convention general session
Seminar (1/2 day) / Forum (full day) presentation (dates to be determined)
Webinar (dates to be determined)
(select all that apply)
Session 3
Session 3 Title:
*
Target Audience:
*
General
Activities Professionals
Administrators (SNF)
Assisted Living Centers
CNA/Caregiver
Dietary Professionals
Environmental Services
Executive Directors (AL)
Nursing Processionals
Skilled Nursing Centers
Social Services
Supervisors
Therapy Professionals
Other
(select all that apply)
Target Audience - Other:
*
Description:
*
Objectives:
*
Length of the session in minutes:
*
Type of Event:
*
Annual convention breakout session
Annual convention general session
Seminar (1/2 day) / Forum (full day) presentation (dates to be determined)
Webinar (dates to be determined)
(select all that apply)
Session 4
Session 4 Title:
*
Target Audience:
*
General
Activities Professionals
Administrators (SNF)
Assisted Living Centers
CNA/Caregiver
Dietary Professionals
Environmental Services
Executive Directors (AL)
Nursing Processionals
Skilled Nursing Centers
Social Services
Supervisors
Therapy Professionals
Other
(select all that apply)
Target Audience - Other:
*
Description:
*
Objectives:
*
Length of the session in minutes:
*
Type of Event:
*
Annual convention breakout session
Annual convention general session
Seminar (1/2 day) / Forum (full day) presentation (dates to be determined)
Webinar (dates to be determined)
(select all that apply)
Session 5
Session 5 Title:
*
Target Audience:
*
General
Activities Professionals
Administrators (SNF)
Assisted Living Centers
CNA/Caregiver
Dietary Professionals
Environmental Services
Executive Directors (AL)
Nursing Processionals
Skilled Nursing Centers
Social Services
Supervisors
Therapy Professionals
Other
(select all that apply)
Target Audience - Other:
*
Description:
*
Objectives:
*
Length of the session in minutes:
*
Type of Event:
*
Annual convention breakout session
Annual convention general session
Seminar (1/2 day) / Forum (full day) presentation (dates to be determined)
Webinar (dates to be determined)
(select all that apply)
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