Wufoo

Date * MM / DD / YYYY
Presenter Information
Name * Title First Last Suffix
Title
Professional Affiliation
Mailing Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Day Time Telephone ### - ### - ####
Evening Telephone ### - ### - ####
Fax Number ### - ### - ####
Email Address *
Curriculum Vitae (please upload) *
Proposed Presentation Summary
Presentation Title *
Presenter * Title First Last Suffix
Co-Presenter Title First Last Suffix
Co-Presenter Title First Last Suffix
Intended Audience *
Presentation Summary *
Learning Objectives *
Instructional Methodologies Employed *
Time Requirement for Presentation *
1 hr 45 min 3 hrs 30 min
Number of Workshops willing to conduct:
(It is requested if you do 1.45 hr workshop that you do a minimum of 3. If you do 3.5 hr workshop that you do a minimum of 2) *
2 3 Other
Schedule/Presentation Limitations: *
Venues (Organization, Location, Date) at which this presentation has been made: *
Available presentation dates: *
July 10, 2018 July 11, 2018 July 12, 2018
Please include following information as attachments:
Bio
Photo
Video (If available)
or paste the video URL(s) below
Workshop description for inclusion in D.A.R.E. Conference book
Presentation Logistical Considerations
Presenter(s) *
Presentation Title *
Audience Size *
Under 25 25 to 50 50 to100 100 to 500 Unlimited Other
Preferred Room Configuration *
Theater Classroom Rounds Other
Audio/Visual Needs *
LCD Projector 35 mm Projector Overhead Projector Screen Microphone Microphone (Wireless) Tape Player CD Player Other (please specify in the Other Audio/Visual Needs field below)
Other Audio/Visual Needs
Handout Materials (attach/forward all handouts) *
Do you need to attach more handout files? *
No Yes
If you need to submit more handout files, please email them as attachments to mistie.bellrenfro@dare.org. Please mention that you submitted your proposal through the online form and include the presentation title and the name of the presenter(s).
Number of handouts *
Do Not Fill This Out

Wufoo

Presenter Information

Proposed Presentation Summary

Please include following information as attachments:

Presentation Logistical Considerations

If you need to submit more handout files, please email them as attachments to mistie.bellrenfro@dare.org. Please mention that you submitted your proposal through the online form and include the presentation title and the name of the presenter(s).