To Healthy LivesIf there will be more than one presenter, please copy and complete all contact and demographic information for EACH presenter (this form can accommodate up to four presenters). Designate a primary contact for the proposal. Only the primary contact will receive a confirmation from the conference committee. It is the primary contact's responsibility to contact and organize with all co-presenters. All presenters must submit a current curriculum vitae, resume or biography (this can be mailed to the Lesbian Community Cancer Project).
Do you need a text-only version of this proposal?
Primary Contact:
Position/Title/Degree/Experience:
Work/Affiliation:
Address:
City: State: Zip:
Email:
Telephone: Fax number:
Gender :
Race/Ethnicity:
Do you need child care?yes
no
If yes, for how many children? Age(s)?:
Do you require adaptive devices/accommodations?: yes no
If yes, please describe:
Do you require translation services?yes no
If yes, please describe:
Number of Co-Presenters: (no co-presenters? Skip to next section)
Presenter #2 (if applicable):
Name:
Position/Title/Degree/Experience:
Work/Affiliation:
Address:
City: State: Zip:
Email:
Telephone: Fax number:
Gender :
Race/Ethnicity:
Do you need child care?yes
no
If yes, for how many children? Age(s)?:
Do you require adaptive devices/accommodations?: yes no
If yes, please describe:
Do you require translation services?yes no
If yes, please describe:
(no more co-presenters? Skip to next section)
Presenter #3 (if applicable):
Name:
Position/Title/Degree/Experience:
Work/Affiliation:
Address:
City: State: Zip:
Email:
Telephone: Fax number:
Gender :
Race/Ethnicity:
Do you need child care?yes
no
If yes, for how many children? Age(s)?:
Do you require adaptive devices/accommodations?: yes no
If yes, please describe:
Do you require translation services?yes no
If yes, please describe:
(no more co-presenters? Skip to next section)
Presenter #4 (if applicable):
Name:
Position/Title/Degree/Experience:
Work/Affiliation:
Address:
City: State: Zip:
Email:
Telephone: Fax number:
Gender :
Race/Ethnicity:
Do you need child care?yes
no
If yes, for how many children? Age(s)?:
Do you require adaptive devices/accommodations?: yes no
If yes, please describe:
Do you require translation services?yes no
If yes, please describe:
Title of Presentation:
Please attach a Program/Workshop Description (200 words or less).
Estimated Time Span:
Program Learning Objectives: Please provide three learning objectives for your presentation. They must clearly state what information, insight or skills you would like others to leave the session with.
At the end of the presentation, participants will:
1.
2.
3.
Program Style: Please indicate one.
Lecture Interactive/Discussion Network building/Working Meeting
Audio/Visual Requirements: Please indicate what you need (NOTE: We cannot guarantee electronic equipment for all presentations but we will make every effort to accommodate you).
Flip Chart VCR/Monitor Slide Projector/Screen Overhead Projector/Screen
Other:
When you submit your request, please be patient. Your information will be converted into an email document and it may take several seconds. Depending on how your web browser is configured, you may be asked to authorize submission of an insecure document (just click OK - it means that email is not absolutely secure but, then again, your program proposal is not top-secret, right?).