To Healthy Lives
If 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).
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: ____
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: _________________________________________________
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: ________________________________________________________
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).
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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: ________________________________________________________________________
You may copy this text and paste it onto your word processor for completion or into your email program.
Return this by U.S. Postal Service to:
LCCP
Conference Planning Committee
4753 N Broadway STE 602
Chicago, IL 60640
or by e-mail to: LBTWHCprogram@uic.edu