Please submit this form 1 month prior to webinar. Rehearsal webinars should be scheduled two weeks prior to the webinar. APA webinars are a benefit of APA membership. If you have any questions, please contact Laura Turner at laurat@academicpeds.org.

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* 1. Date(s) of webinar:

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* 2. Date(s) for rehearsal webinar(s):

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* 3. Faculty name(s):

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* 4. Email address(es):

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* 5. Description of webinar(200 words max):

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* 6. Learning objectives:

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* 7. Additional staff support needed (describe additional APA staff time and resources needed besides setting up the webinar, sending out 3 announcements for the webinar and inputting the survey/polling questions into the webinar):

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* 8. Please include any of the following information to this form:
- Surveys (pre and post)
- Polls
*Please note these should be formatted for Canvas or GotoWebinar

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
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* 9. Brief bio(s) for webinar leads- (250 words max)

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