Presenter Application Form

The information below is for Evergreen's event coordination use as well as conference materials.  If it is ok with you, we'd like to help participants contact you.  If you want any information provided to remain confidential, simply note that below.

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* 1. Speaker Name (s) & Title (s)

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* 2. Organizational Affiliation (if any)

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* 3. Speaker  Mailing Address, City, State, Zip (If you would like this to remain confidential please note that below)

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* 4. Phone Number (if you would like this to be confidential please note that below)

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* 5. Cell Phone (for last minute contact from Evergreen; please note that we won't share it with participants).

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* 6. Email address (if you do not wish this shared with participants, please note that below).

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* 7. Speaker Bio Sketch. Please write a 2-3 sentence description of each presenter describing current work affiliations, educational background, special licenses or certifications (for CEUs and introductions). We would appreciate a copy of each presenters' resume or bio if available, please email to Kari at kbloomquist@evergreenyfs.org.

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* 8. Title of your 1st Presentation (if you are doing more than one)

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* 9. Length of Presentation: 75 minute break-out sessions, inclusive of questions & answers.  It is important that presentations begin and end on time. Please note below if you would like a double session so participants attend a Part I and Part II

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* 10. Presentation format (eg. personal story, lecture, panel, interactive presentation or other)

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* 11. Is there a specific audience knowledge level required for the target audience?  Is your target audience more specific than parent or professional?  Is this for clinicians, treatment providers, others?  Please explain.

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* 12. Please provide a description of your 1st presentation for the conference brochure & CEU applications.   Participants are most interested in hands on action items they can use when working with people.

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* 13. 1st presentation: Please provide 3 learning objectives for participants (required for CEU applications).

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* 14. Title of your 2nd Presentation (if you are doing more than one session; if you are not doing a second presentation please skip to question 20)

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* 15. Length of Presentation: 75 minute break-out sessions, inclusive of questions & answers.  It is important that presentations begin and end on time. If this is a two part presentation please note that below.

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* 16. Presentation format (eg. personal story, lecture, panel, interactive presentation or other)

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* 17. Is there a specific audience knowledge level required for the target audience?  Is your target audience more specific than parent or professional?  Is this for clinicians, treatment providers, other?  Please explain.

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* 18. Please provide a description of your 2nd presentation for the conference brochure and CEU applications.  Participants are most interested in hands on action items they can use with their clients.

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* 19. 2nd presentation: Please provide 3 learning objectives for participants (required for CEU applications).

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* 20. Which days and times are you available to present?  We may ask you to present a breakout session more than once over the two day period.  Please list all times you are available.

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* 21. Compensation (Please use comments box to confirm which compensation items you are requesting)

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* 22. Conference Participation (thanks for helping us plan meals and beverage breaks)

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* 23. Please print a copy of this document for your records. If you would like me to email you a copy of this please let me know, kbloomquist@evergreenyfs.org.

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* 24. Please list any other questions you have or contact the Conference Registrar, Kari Bloomquist at (218) 441-4562 or kbloomquist@evergreenyfs.org. Please allow 24 hours for response.

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